October 28, 2016 Susana Viera Transportation Application Your Name (required) Date (required) Form Name Date of Birth Address City State Zip eMail Home Phone Cell Phone Emergency Contact Emergency Phone Primary Care Provider PCP Address PCP Phone Diagnosis Multiple SclerosisParkinson'sMachado-JosephOther Neurological Disorders Have you obtained a medical certification letter? yesno If no, please request your PCP or Neurologist mail or fax one to the Susana Viera MS Foundation. Agreement: By submitting this application, I affirm that the facts set forth in it are true and complete. I understand that any false statements, omissions, or other misrepresentations made by me on this application may result in disqualification of services.