Activate An Air Ambulance Flight -

Air-Ambulance Activation

You are Assured of Wellness & Happiness.

Activate Your Air-Ambulance Request

Provide the details in the form provided below, and we shall initiate the Air-Ambulance Activation request.

1About Patient

2Current Medical Facility

Patient Details:
Name*
First Last
Sex:*
- Male
- Female
Age:*
Date of Birth:
MM slash DD slash YYYY
Nationality:*
Height:

(In Centimeters)
Weight:

(In Kilograms)
Upload Patient's Passport Copy:
Accepted file types: jpg, gif, png, pdf, Max. file size: 512 MB.
Upload Patient's Diagnosis and Current Medical Report:
Accepted file types: pdf, doc, docx, Max. file size: 512 MB.
Applicant's Email ID:
Applicant's Phone Number:*

Current Patient Location:
Hospital Name:
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Doctor's Name:
First Last
Doctor's / Medical Facility's Email ID:
Doctor's / Medical Facility's Phone Number:
Confirmation whether there is a local ground ambulance available to assist with the movement of the patient and medical flight crew
- Yes
- No
Note:

From time to time and depending on the patient profile it may be necessary to obtain a 21 day travel history, we will advise should this be required.

VERY IMPORTANT: PATIENTS AND TRAVEL COMPANIONS ARE PERMITTED TO CARRY ONE ARTICLE OF LUGGAGE ONLY WHICH SHOULD NOT EXCEED THE SIZE OF AN OVERNIGHT TRAVEL/CARRY ON TYPE BAG. WE WILL NOT BE HELD RESPONSIBLE FOR LUGGAGE OR ITEMS THAT REMAIN BEHIND DUE TO SPACE RESTRICTIONS.

Health Insurane Solutions

We are committed to serve you better. By disseminating our industry expertise, we offer you the best medical insurance solutions & to include emergency medical evacuation.

Air-Ambulance Activation

You are Assured of Wellness & Happiness.

Activate Your Air-Ambulance Request

Patient Details:

Current Patient Location:

Note:

Health Insurane Solutions

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