PFP - Mission Request

Mission Request

Printable forms

Please review the basic acceptance factors
You will need to complete the following forms and fax them to the Pilots for Patients office (318-388-4924):

The patient and companion will be asked to sign the waiver form each and every time they fly. It is included here for the social worker and patient to review.

The request for transportation and the physician's statement (with a handwritten signature) need to be faxed to our office (318-388 4924). Keep in mind we need 5 working days notice for flight requests. The 5 days notice does not begin until we receive all paperwork.

You can also reach us here.

Online form

Please fill in the appropriate information, so we can start planning the mission. You will also need to download the waiver of liability and physician's statement forms and mail or fax them to us signed. Thank you!

Requester Information

*=Required Fields
Enter all Dates using Format: mm-dd-yyyy
Enter all Phone # using Format: xxx-xxx-xxxx

Privacy Statement

*Requester Name:(First, Last)	Date:
	2/8/2012
Requester E-Mail Address
*Facility Name

*Facility Phone#		Facility Fax#:

Mission Information

*From city:	*State: (caps)

*To city:	*State: (caps)

Hospital/Clinic:	Phone:

Appointment date:	Appointment time:
	Example: 9am

*Flight date:	Return date:
	(blank if return transport not needed)

Patient Information (weight limit per person is 250 lbs)

*Name	*Age	*Weight

Address:

City:	State:	Zip:

County:	*Phone:

*Medical Condition:

Communicable Oxygen required

Companion 1:	Age	Weight

Due to space limits, Only 1 Companion Allowed!
:

Doctor Information

*Name

*Hospital/Clinic:

Address:

City:	State:	Zip:

*Phone:	Fax:

Mobile:	Pager:

Miscellaneous Information

If you have any further information or comments, please let us know: