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Mission Guidelines
Please complete the following - this is the first step in requesting a mission flight. In order to be eligible you must agree to the following list of criteria. Upon completion, you will be taken to a form to submit your specific information. Our mission coordination team will review your request and follow-up with you as soon as possible.
Please complete the following:
Please use Mozilla Firefox to fill out the following forms.
Patient's Name
*
Today's Date
*
Name of person filling out form
*
Your Phone #
*
Relationship to patient
*
To be considered for free air transportation, please check all of the following that apply
Patient Agreement
Medical treatment is not available locally
Car travel is too difficult / time consuming
Patient cannot afford alternative travel costs
Patient is not able to travel on public transportation due to condition
All patients must agree to and understand the following before being accepted for free air transportation
Patients must agree to each of item listed
Adults must sign a waiver for themselves & minors
Or be able to reschedule flight
Patient agrees not to exceed wt given for baggage
Patient allows ANGEL FLIGHT
TM
to share patient info
Patient is able to ride in a small plane with NO Bathroom
Patient is able to walk & climb stairs Unless the patient is a child under 6 years old and can be carried
Patient is responsible for ground transportation
Patient understands weather can cancel mission
Patient will give handwritten thank you note to pilot
Patient will not wear colognes or perfumes on day
Patient will provide physician name, address, phone and fax number
Wheelchairs or strollers aren't permitted on plane
Name
*
I agree to the above guidelines
*
Agree
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