Mission Intake Form
To be considered for free air transportation, please answer all questions
Necessary medical care is required
Patient cannot afford is required
No Public Transporation is required
All patients and passengers must agree to and understand to the following before being accepted for free air transportation
Walk and Climb is required
Physician Name is required
Ground Transportation is required
Not to Exceed is required
Strollers Not Permitted is required
Must sign Waiver is required
Handwritten note is required
Allow Patient Info is required
Acknowlege Weather is required
Patient will call is required
Patients grant is required
Contact Information (if different from patient)
Patient Information
Patient Gender is a Required Field
Patient Insurance is a Required Field
Medical
*** Please Note: wheelchairs must be shipped ***
Origination and Destination
Origination State is a Required Field
Origination City is a Required Field
Destination State is a Required Field
Destination City is a Required Field
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