Medical Air Transportation Inquiry

Complete the transfer form below for a flight coordinator to contact you with information concerning your air ambulance questions or needs. You must include a phone number and/or email address in order for us to contact you. Keep in mind that we follow all HIPAA rules and regulations, assuring your privacy.

TRANSFER INQUIRY
This transfer is for:
Contact Name:
Company:
Street Address:
City:
State:
Zip Code:
Country:
Telephone #1:
Telephone #2:
E-mail Address:
FAX:
Relationship to Patient:
Patient Name:
Patient Diagnosis:
Type of Transfer:
Date of Transfer (if known):
Transfer FROM
Name of Hospital / Other:
City:
State:
Country:
Transfer TO
Name of Hospital / Other:
City:
State:
Country:
Have you used our services before?	Yes No
Additional Comments:

flight for life