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Mission Request
What you should know before you fly

Pilots for Patients would like to encourage evey pilot, patient, and companion to watch this short clip on passenger safety. This video may answer questions and help you prepare for future flights with one of our PFP Volunteer Pilots.

FAA - Safety Video

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
Privacy Statement

Date: 6/28/2017

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

Welcome to our online scheduling. We will make every effort to accommodate your request. While we strive to find a pilot for each request, all patients are encouraged to have a backup plan should we be unable to fill their flight requests.

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

Requester's Information
Requestor's First Name: *
Requestor's Last Name: *
Requestor's E-mail Address:
Requestor's Facility Name: *
Requestor's Facility Phone#: *
Requestor's Facility Fax#:

Flight/Mission Information
From City: * State: *
To City: * State: *

Patient's Appointment Information
Visiting Hospital/Clinic Name:
Visiting Hospital/Clinic Phone#:
Patient's Appointment Date:
Patient's Appointment Time: (Example: 9am)
Patient's Flight Departure Date: *
Patient's Flight Return Date: (Leave blank if return transport not needed)

Patient Information (weight limit per person is 250 lbs)
Patient's Name: *
Patient's Medical Condition: *
Patient's Phone#: *
Patient's Age: *
Patient's Weight: * (weight limit is 250 lbs)
Patient's Address:
Patient's City:
Patient's State: (select a city first)
Patient's Zip:
Patient's County:
Check all that apply: A Veteran             Employed     On Public Assistance
Communicable      Oxygen required

Patient's Emergency Contact Information
Emergency Contact's Name:
Emergency Contact's Phone#:

Companion's Information (Due to weight limits, only one companion is allowed.)
Companion's Name:
Companion's Age:
Companion's Weight: (weight limit is 250 lbs)

Doctor's Information
Doctor's Name: *
Doctor's Phone#: *
Doctor's Mobile#:
Doctor's Fax#:
Doctor's Pager#:
Doctor's Hospital/Clinic: *
Doctor's Hospital Address:
Doctor's Hospital City:
Doctor's Hospital State: (select a city first)
Doctor's Hospital Zip:

Miscellaneous Information

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

Enter text here as shown in image:
     
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