New Patient Inquiry Please complete the form below; a timely response will follow. All information will be kept strictly confidential and is intended solely for the purpose of determining the best mode of transportation and patient care requirements..     About the Patient               What is the Patient's Diagnosis / Medical Condition Patient Age    Weight Is the patient currently in the hospital? No Yes When admitted   Can the patient walk? No   Yes, with assistance   Yes, unassisted   Is the patient continent?   No   Yes   I don't know   Can the patient sit up?   No   Yes   How long?   Where is the patient now ? (e.g facility - city - state - country) What is the destination? Approximate travel date?               Special Needs and Requirements               Is the patient on oxygen?   No   Yes   how much?   Does the patient have any IV's?   No   Yes   Is the patient on a special diet?   No   Yes   Explain   Tube feedings required?   No   Yes   Does the Patient have a foley catheter?   No   Yes   Please describe any special equipment needs? (ie: Ventilator)               Contact Information (* Indicates required)               Your Name*   What is your relationship to the patient? Patient's Name   Home Phone Number* Email Address*   Work Phone Number How did you hear about us?   Cell Phone Number