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.

Follow-up Contact (person who should be contacted)

Primary Passenger

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

Travel Information

Escort Information

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

Screening Information

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

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

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)   characters remaining

Physician Information

Prior to coordinating the flight, we must obtain a medical release from your personal physician. We also request that you provide information on the treating physician at your destination.

Personal Physician (Your primary physician)

Treating Physician Information (Physician you are traveling to see)

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:

 Yes  No