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Limitations on Weight and Space

The aircraft we use have limited space and restricted weight-carrying capability. Passengers should plan to travel light, shipping extra luggage or equipment ahead may be necessary. Private planes typically have seating for two to three passengers. Each plane has a weight limit that must be observed. An exact baggage weight will be given to you once your mission is approved. One or two small soft-sided gym bags are acceptable. A soft-sided gym bag is preferable because it permits the most efficient use of space.

At the time you request a flight, please be prepared to give us the exact weights of the passengers.

Acceptable Baggage

 

 

 

 


Unacceptable Baggage

 

Mission Intake Form

To be considered for free air transportation, please answer all questions

The necessary medical care/ second opinion/ specialist 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 / immune deficiency  *

All patients must agree to and understand to the following before being accepted for free air transportation

Patient is able to walk & climb stairs (unless the patient is a child under 6 years old and can be carried)  *Patient will provide physician name, address, phone and fax number  *Patient is able to ride in a small plane with NO bathroom  *Patient is responsible for ground transportation to and from airports  *Patient agrees not to exceed weight given and must use soft sided bag Patient will not wear colognes or perfumes on day of flight  *Wheelchairs or strollers are not permitted on plane with the exception of collapsible umbrella strollers  *Each adult must sign a waiver for themselves and minors, that will be provided by volunteer pilot at airport before boarding  *Patient agrees to give handwritten thank you note to pilot  *Patient allows ANGEL FLIGHT SOARSTM to share patient information with sister organizations as needed to coordinate mission  *Patient acknowledges that weather can cause the mission to be canceled and will have other transportation available or be able to reschedule flight  *Patient will call if he/she makes other travel plans or appointment date/time changes  *I agree to the above guidelines  *Date  *

Contact Information

Name if different from patient Your Phone # 

Patient Information

How did you hear about Angel Flight?  *Patient First Name  *Last Name  *Gender  *Race  *Weight  *Height in Feet  *Height in Inches Date of Birth  *Age  *Insurance  *If Private please indicate provider: Combined Household Income  *Please DO NOT use the dollar sign ($) symbol.

If your income is $10,000 please enter as 10000 Employer Patient Address  *Patient Address Continued City  *State  *County  *Zip Code  *Phone #1  *Phone #2 Phone #3 Email Are you or any of your immediate family active military or veteran How many people in your household?  *

Medical

Medical Affliction  *Transplant Patient  *When you receive your "Live Call" how many hours do you have to get to the facility? Do you use any of the following? 

*** Please Note: wheelchairs must be shipped ***

Reason for Visit  *

Origination and Destination

Origination City  *Origination State Destination City  *Destination State  *Appointment Date Time of Appointment 









How long at Appt.? 

Ground Transportation and Lodging

Ground Transportation Ground Transportation Phone Lodging at Destination Lodging Destination Phone 

Passenger Information

1st Passenger First Name 1st Passenger Last name Relationship to Patient 1st Passenger Phone 1st Passenger Gender 1st Passenger Race 1st Passenger Weight 1st Passenger Height in Feet 1st Passenger Height in Inches 1st Passenger Date of Birth 1st Passenger Age Military/Veteran 1st Passenger Address 1st Passenger City 1st Passenger State 1st Passenger County 1st Passenger Zip 2nd Passenger First Name 2nd Passenger Last Name Relationship to Patient 2nd Passenger Phone 2nd Passenger Gender 2nd Passenger Race 2nd Passenger Weight 2nd Passenger Height in Feet 2nd Passenger Height in Inches 2nd Passenger Date of Birth 2nd Passenger Age Military/Veteran 2nd Passenger Address 2nd Passenger City 2nd Passenger State 2nd Passenger County 2nd Passenger Zip 

*** Baggage must be in soft sided bag ***

Total Baggage Weight 

Primary Doctor Information

Doctor you have seen recently  *Attn: Referring Facility Phone #  *Fax #  *Referring Facility Address  *Primary Doctor City  *Primary Doctor State  *Primary Doctor Zip  *Doctor you have seen E-Mail 

Doctor at Destination

Doctor at Destination Attn: Destination Facility Phone # Fax # Destination Facility Address Destination Doctor City Destination Doctor State Destination Doctor Zip Doctor at Destination E-Mail