Air Ambulance America: Wings of Medicine

Patient Information Sheet

PATIENT INFORMATION SHEET NON-EMERGENCY MEDICAL TRANSPORT

 

SCHEDULED DATE OF TRANSPORT: ____________________
TIME: _______________ (AM/PM)

 

Patient Name:


(Last) _________________ (First) _____________ (Middle) ________

Patient ID (Hospital ID Number): ___________________________________

Room _______________

DOB: ___ (Month) _____ (Day) _____ (Year)

Home Address: (Street) ________________________________________________ (City)_______________________ (State) _______ (Zip) _________

 

Family Member or Legal Guardian Contacts:

 

(1) Name ________________________________________

Relation to Patient _____________________________

Tel: __________________________________________

 

(2) Name ________________________________________

Relation to Patient _____________________________

Tel: ________________________

 

Discharging Physician:_______________________________

Tel: __________________________
Email: _____________________________


Receiving Hospital/Facility: __________________________

(Street)_________________________________________________

(City) _______________________ (State) _________ (Zip) ________

Tel: ___________________________

Email: _________________________

 

Receiving Physician: __________________________________

Tel: ______________________________

Email: ____________________________

Call our call center 24/7/365!
1-800-827-0745 or International (USA country code)+305.662.4006

 

**About Air Ambulance America (AAA): Air Ambulance America is an authorized indirect Air Carrier (IAC) utilizing the services of licensed Part 121 and 135 air carriers to meet your air ambulance transportation need. AAA does not own,lease or operate aircraft, and has no affiliation with any direct air carrier. As an IAC, AAA contracts for the provision of air transportation services in its own name and coordinates the provision of medical services for your flight.
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