flight-ambulance-booking-form

Booking Request Form

Please complete the following form to allow us to provide you with an accurate pricing estimate. A full quotation will be provided once we have all the required details and is valid for 7 days.

We generally require 48 hours notice for a booking, however subject to vehicle/crew availability, we may be able to work on a shorter notice period.

You

What is your relationship to the patient?

This form should be completed by the patient, family member, insurance company, medi flight coordinator or the person responsible for paying the bill. Required

Your Name

Company Name

What is your telephone number, please include your country code

Contact email address

Patient Details

We require some basic details relating to the patient.

Patient Name

Date of Birth of the patient

Europe/London

Patient Gender

What is the planned date for the transfer?

Europe/London

Which hospital are we transferring from?

Hospital Address

Province

Will the patient have a supplied medical escort?

What is the patients mobility?

Airport

Which airport is the patient being transferred to?

Boarding Arrangement

Payment

How will payment be made? Our standard terms are 14 days.

Other information

Please let us know about any specific requirements relating to this transfer, for instance, will there be any relatives travelling from the hospital with the patient,?

Please add comments here