Mission Intake Form
To be considered for free air transportation, please answer all questions
All patients and passengers must agree to and understand to the following before being accepted for free air transportation
Contact Information (if different from patient)
Patient Information
Medical
*** Please Note: wheelchairs must be shipped ***
Origination and Destination
(Select from the drop down box or start typing to search)
Ground Transportation and Lodging WHILE AT TREATMENT
Passenger #1 Information
*** Baggage must be in soft sided bag ***
You be be told your baggage allowance when a member of the mission team calls to speak with you.
Primary Physician Information
Physician at Destination