ANGEL FLIGHT PATIENT ENQUIRY FORM

Please fill all the fields

Required fields are marked *

Patient first name *:
Patient last name *:
Patient date of birth *:
Patient gender *:	--------- Male Female Other
Patient 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:
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?