FLIGHT REQUEST FORM
Email *
Patient Information
This form collects information for us to assess how best to help you. We treat all information as confidential and your personal information is never shared outside of the Angel Flight East Kootenay organisation.
Some of the questions are for statistical information purposes and are noted as such.
Patient first name *
Patient last name *
Patient date of Birth *
Month/Day/Year
MM
/
DD
/
YYYY
Patient gender
Clear selection
Your preferred phone number (we'll use this to contact you if we need to confirm information with you). If you have a cellphone, please use this number. *
Please enter in the format xxx-xxx-xxxx
Patient street address *
Patient town *
Emergency contact name (cannot be on your flight) *
Emergency contact relationship *
Emergency contact phone # *
Please enter in the format xxx-xxx-xxxx
Do you need assistance boarding the plane? The boarding process involves approaching the plane and climbing into it. Note that unfortunately at this time we cannot accommodate walkers or wheelchairs. *
Do you have any breathing problems? *
If you answered YES to breathing problems above, please add more detail
Do you use home oxygen ?
Clear selection
If you answered YES to home oxygen use above, please add more detail
Are you anxious about flying in a small plane?
Clear selection
Weight of patient (in pounds) * *
Weight of baggage (in pounds) *
Appointment Details
Destination *
Family Doctor’s name
Appointment Doctor’s name
Medical appointment date (leave blank if unknown)
MM
/
DD
/
YYYY
Medical appointment time (leave blank if unknown)
Time
:
What is the length of your appointment?
Date flight required
MM
/
DD
/
YYYY
Estimated date of return
MM
/
DD
/
YYYY
Escort Information
Your escort needs to complete a waiver but does not need to get the doctor to sign it.
Do you want to bring an escort?
Clear selection
Name, age and relationship of escort
Weight of escort (in pounds)
We may need to use your escort's seat for another patient and we can't guarantee that the escort will be able to travel with you. Is this okay with you
Clear selection
If you answered NO to the above escort question, please add more detail
Waiver
Note that if you are going for surgery or a procedure where you will be sedated you must take another waiver form for the discharging doctor to sign before your return flight.
Medical clearance is required from your doctor. Have you completed and signed the waiver? *
Additional Information
Do you require transport at the destination?
Clear selection
What is your back-up plan should the flight be cancelled?
Clear selection
Please use this space to tell us anything else we should know in order to arrange your flight
Some statistical information.
This is useful to us in fundraising and improving the effectiveness of the community service that we offer. Please do not answer these questions if you feel uncomfortable.
What hospital department are you visiting?
How did you hear about us?
Clear selection
You are done! Thank you!
Please check your responses carefully and submit the form to us. We will get back to you as soon as possible.
Your Privacy
We greatly respect your privacy and diligently guard this and any other information that you may share with us in the future.
We do not share anything about your medical condition that you may disclose with our pilots nor with ground staff.
After completion of a flight, your data is anonymised for your privacy and security.
If you have any concerns, please do not hesitate to contact us.
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This form was created inside of Angel Flight East Kootenay. Report Abuse