Medical Evacuation Form

Contact Person's Name * e.g: John Smith

Patient Name * e.g: Robbert Meridth

Patient Weight e.g: 180

Weight Type e.g: KG/LBS

Patient Height e.g: 180

Height Type e.g:Feet/Inch/CM

Patient Gender *

Age Year e.g: 10 Years

Age Months e.g: 3 Months

Age Days e.g: 1 Day

Has hospital admission been confirmed at arrival port? Yes No

Do you have a valid travel insurance policy? Yes No

Nurse Medical Escort Yes No

Contact Person's Tel * e.g: +(92)(300)8000000

Email e.g: abc@gmail.com

Have ambulance arrangements been confirmed at departure port? Yes No N/A

Have ambulance arrangements been confirmed at transit port? Yes No N/A

Have ambulance arrangements been confirmed at arrival port? Yes No N/A

Patient's Nationality e.g: Pakistani

Patient's Identity No e.g: xxxxx-xxxxxxx-x

Patient's Passport No e.g: xxxxxx

Stretcher needed? Yes No

Incubator needed? Yes No

Wheelchair needed? Yes No

Stretcher Service Required? Yes No

Own wheelchair? Yes No

Collapsible? Yes No

Power riven? Yes No

wheelchair requested from airline? Yes No

Dispatching Hospital Name e.g: Jinah Hospital

Receiving Hospital Name e.g: Mid Cheshire Hospital NH street

Dispatching City,Country e.g: Lahore, Pakistan

Reveiving City,Country e.g: London, UK

Intended Departure Date e.g: 09/10/2016

Intended Arrival Date e.g: 09/10/2016

Patient's Prefered Language e.g: English,Urdu, ...

Diagnosis/Condition

Notes / additional information

Medical Escort (Doctor Accompanying) Yes No

Medical Escort (Specialist Accompanying) Yes No

Medical Escort (Nurse) Yes No

Accompanying Passengers

Escort (Doctor)

Escort (Nurse)

Escort (Specialist)

Intentded Escort Details e.g: Additional Information

Are any special in-flight arrangements ? e.g: Special meals, special seating, extra seat(s), special equipment etc.

This is a preliminary query form our Control Room shall get Intouch with you shortly. Alternatively contact us on our 24/7 Hotline. +(92)(300)(8468763).

Please Complete Medical Evacuation Form

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