Request for Charitable Transportation Assistance

Please complete this information for the Patient or Primary Passenger who has a need for transportation. It is important that you provide a follow-up contact person for us to call to respond to your request. This may be a social worker, parent, or yourself as the passenger. Required fields are marked with an asterisk. Additional information may be required to complete the mission request after we follow up.

Please note:

• You must be able to board a commercial airline coach seating on your own and sit up in a seat with a seat belt fastened around you and travel without medical care during the flight.

• Your travel must be within the United States or United States territories.

Items marked with * are required entries.

Follow-up Contact (person who should be contacted)

Primary Passenger

IMPORTANT: Use Full Legal Name as it appears on your ID Card.

Travel Information

Facility to which you are traveling

Escort Information

IMPORTANT: Provide Full Legal Name as it appears on the escort's ID Card and all additional information about the escort.

Screening Information

Special Requests

Financial Situation* - Brief description of the financial situation that warrants a charitable flight

Reason for the Flight* - Brief description of passenger's illness, diagnosis, or reason for needing the flight

Brief description of other conditions - These may or may not be related to this flight (example: high blood pressure, heart condition, asthma or breathing problems, chest pain, a head cold or sinus infection)

Personal Physician Information

Prior to coordinating the flight, we must obtain a medical release from your personal physician who has recently seen you in their office and is familiar with the date, location and the purpose of the medical appointment you are traveling to. Do not add your personal email address here ONLY physician email address - if you do not know it please do not include it.

IMPORTANT: I authorize Mercy Medical Angels to contact my physician through the information I have provided to obtain a medical clearance form showing proof of appointment:*