AeroMedical Transport Specialists - air ambulance air medical transport flight medical

 
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"Over 48 Years
of  Experience"
Air ambulance,
air medical transport, 
air escort and 
medical flight

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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