2SELECT FLIGHT TYPE

Airplane Helicopter

3CONTACT DETAILS

Company Invidual Name Surname Email Contact number Contact Address City Country

4ITINERARY DETAILS

5SPECIAL INFORMATION

Is the Patient medically cleared to fly ? Yes No Can the Patient walk ? Yes No Flight Doctor Required ? No Yes Accompanying Personal Doctor ? No Yes Special Equipment Required (ICU, oxygen, etc) Please Detail Number of People accompanying Patient 0 1 2 3 4 5 Will you arrange for conveyance to the aircraft (e.g. ambulance) ? No Yes Will you arrange for an ambulance to meet the aircraft ? No Yes

6SPECIAL INFORMATION

Small luggage 0 1 2 3 4 5 6 7 8 9 10 Large luggage 0 1 2 3 4 5 6 7 8 9 10 Pushchair No Yes Extra luggage No Yes

7PAYMENT DETAILS

Select payment method Credit Card Bank Wire transfer Paypal

8TRAVEL ARRANGEMENTS

Request any car services here

Request any connecting flights here

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