passenger form test Passenger Intake Form Passenger intake form Step 1 of 7 - General Contact Info 0% Legal Name(Required) First Last Email(Required) Phone(Required)CAPTCHA Has the patient flown with us before?(Required) Yes No Who is requesting the flight?(Required) Patient Parent or Guardian Friend or Relative Social Worker Physician or Physician's Office Staff Other Let's just grab some information about the patientLegal Name(Required) First Last Email(Required) Phone(Required)Patient Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Height (feet)Height (inches)Weight (lbs)Date of Birth(Required) Month Day Year Is the patient traveling with a companion?(Required) Yes No Who should we contact regarding this flight?(Required)PatientCompanionOk, please provide some information about the companionCompanion contact information(Required) First Name Last Name Relationship to the patient(Required)SpouseParentGrandparentCaregiverFriendOtherPhoneEmail(Required) Companion Address(Required) Street Address Address Line 2 City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Height (feet)Height (inches)Weight (lbs)Date of Birth(Required) Month Day Year Appointment Date MM slash DD slash YYYY Appointment TimeHourHR121234567891011Minute00153045AM/PMAMPMAre there any special requirements? (Walker, stroller, oxygen, etc) Yes No Can you tell us what those are? Just need some quick info about your physician(s) and treatment facility.NOTE: We will require a medical release from your physician in order to travel with usPhysician providing medical release NOTE: Must have visited within the last 6 months. It's ok if you don't have this handy, we can gather this information when we speak with you.Treating Physician First Last PhoneEmail FaxReleasing Physician First Last PhoneEmail FaxCan you tell us about the patient treatment facility?Treatment Facility Name Is the patient active duty or a retired veteran? Yes No Don't know Great, do you know which branch of the military?Air ForceArmyMarinesNavyCoast GuardHas the patient or companion ever been convicted of a crime?(Required) Yes No Don't know Ok no problem, please tell us a bit more about the details of the crime(s) Does the patient or companion have a history of behavioral issues and/or specific behavioral issues that could distract the pilot, including seizures? Yes No Don't know Can you explain more? Do you have an economic need for a PALS SkyHope flight?(Required) Yes No
