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