FLIGHT REQUEST FORM
Your Information
Patient name & age *
Your answer
Patient email address *
Your answer
Your best phone # *
Your answer
Emergency contact name, relation and phone # (can not be on your flight)
Your answer
Patient address including Town
Your answer
Appointment Details
Destination *
Your answer
Date flight required *
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DD
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YYYY
Medical appointment date and time *
Your answer
Family Doctor’s name
Your answer
Appointment Doctor’s name and department
Your answer
Estimated date of return
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/
DD
/
YYYY
Additional Information
Weight of patient (in pounds) *
Your answer
Weight of escort (in pounds) *
Your answer
Weight of baggage (in pounds) *
Your answer
Is transport required at destination?
Medical clearance is required from your doctor. Have you completed and signed the waiver?
What is your back-up plan should the flight be cancelled?
Your answer
Any other information for us?
Your answer
How did you hear about us
Your answer
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