ANGEL FLIGHT PATIENT ENQUIRY FORM

Required fields are marked *

Please provide as much information as possible

Patient first name *:
Patient last name *:
Patient date of birth:
Patient gender:	--------- Male Female Other
Patient primary (cell, if owned) telephone number (format xxx-yyy-zzzz) *:
Patient secondary telephone number (format xxx-yyy-zzzz):
Patient email address *:
Patient street name and no (or PO box):
Patient town/city:
Patient postcode:
Patient weight (lbs):
Patient baggage weight (lbs):
Does the patient need assistance to walk/climb stairs?	Yes No
Does the patient suffer any breathing problems?	Yes No
If yes above, please provide some information:
Does the patient use bottled oxygen at home?	Yes No
If yes above, please provide some information:
Is the patient anxious about flying in a small plane?	Yes No
Patient emergency contact name:
Patient emergency contact telephone number (format xxx-yyy-zzzz):
Relationship of emergency contact to the patient:
Where is the patient's appointment?
Patient family doctor:
Patient appointment doctor:
Patient appt date:
Patient appt time:	hh:mm 24hr clock
Patient appt length:
Patient flight reqd date:
Estimated return date from appointment:
Does the patient have more than one appointment on this visit?	Yes No
If yes, please provide more details:
Is the patient undergoing surgery (sedation)?	Yes No
Does the patient want an escort to travel with them?	Yes No
Is the escort strictly required?	Yes No
If escort is strictly required, please provide some information:
Patient escort name:
Patient escort age:
Escort weight (lbs):
Escort baggage weight (lbs):
What is the patient's back-up plan if unable to fly?
Please add any other information which might help:
With which hospital specialty is the patient appointment?
How did you hear about Angel Flight?