Reproductive Care Ride Request

Free Ride Request Form

Please complete this form to request a ride to a reproductive care appointment. Rides will be scheduled Monday-Friday from 9am to 5pm. Any requests put in after 5pm on Friday will not be received until 9am the following Monday.
Holiday Closing Alert: ACC will be closed December 23rd - January 1st. If you are in need of a ride during this time, please submit all ride requests no later than 5pm December 20th. We will resume reviewing ride requests at 9am on January 2nd.
Name*

First NameLast Name
Email*
example@example.com
What's your preference for communication?

Phone callText
Phone Number*
Please enter a valid phone number.
Will you be over the age of 19 at the time of this appointment?*
We do provide rides for minors, but we have special consideration around booking.
Are you currently pregnant?*
If you are currently pregnant, please select your estimated due date:

MonthDayYear
Date
Please Select Appointment Type*
Reproductive care related appointments include prenatal and postpartum doctor’s appointments, appointments related to gender affirming care, routine OB-gyn appointments, dentist appointments for pregnant people, appointments for pelvic floor therapy, mental health appointments, newborn pediatric appointments, appointments relating to Medicaid or WIC, STI screenings, support groups related to reproductive care and MORE. If you think it relates to reproductive care but it’s not listed here, complete the form and let us know. At this time, ACC does not cover rides to personal residences, day care, work, grocery stores or other retail, schools, or sporting events.
If you selected "Other" or if you selected "support groups related to reproductive care" please give name of support group, and/or link here. You can upload a picture of the flyer or social media post below:*
For support groups, please include the name of the person or organization hosting the support group.
File Upload

Cancelof
Appointment Date*

MonthDayYear
Rides will be scheduled Monday-Friday from 9am to 5pm. Any requests put in after 5pm on Friday will not be received until 9am the following Monday. Ride requests are not monitored 24/7. Rides are always subject to the availability of drivers.
Appointment Time*

Hour Minutes

AM/PM Option
Pick Up Address*

Street Address

Suite/Office/Building Number

CityState

Zip Code
Appointment Address*

Street Address

Street Address Line 2

CityState

Zip Code
Return Address (if different than pick up address)

Street Address

Street Address Line 2

CityState

Zip Code
Number of passengers including you*
Another adult can ride with you to your appointment. We'll do our best to accommodate requests to have a child ride with you. We are not currently able to provide car seats or booster seats. If you are requesting a ride for someone under 16 to ride alone, please email lindsey@alabamacohosh.org. These rides typically require more time to book; please contact us at least five days in advance to ensure we can make these arrangements.
Do you have medical insurance?*
Your answer to this question will not influence whether or not we book a ride with you.
Disclaimer

Please keep in mind that ACC have no control over Lyft's drivers, vehicle conditions, driver cancellation, etc. ACC is not responsible for any missed rides or driver no shows, as rides are not guarenteed. Please note that we are not always able to accomodate same day ride requests.
I agree to the terms of ACC's Transportation Waiver and Assumption of Risk Agreement.*

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Free Ride Request Form

Holiday Closing Alert: ACC will be closed December 23rd - January 1st. If you are in need of a ride during this time, please submit all ride requests no later than 5pm December 20th. We will resume reviewing ride requests at 9am on January 2nd.

Disclaimer

Demographic Information