Flying Nurses International - TRANSPORT INQUIRY FORM

All information remains confidential. Contact will be made only with the person sending this inquiry. Please complete all requested information. " don't know" for any uncertain responses. Anticipate a timely response.

Contact Information: *required
Your Name: *
Preferred number and time zone: *
Home Phone:
Work Phone:
Cell Phone:
Time Zone:
Other contact number :
Email address : *
Patient's name :
Your relationship :
How did you hear about us ?

Patient Information:
Diagnosis and brief history of current medical condition:
Age:		Weight:
Can the patient stand? Ambulates Partial weight bearing with assistance No (full lift for transfer)  Add'l details:
Can the patient sit up?
Wheelchair:		Yes   No
Reclining bedside chair:		Yes   No
How long?		Add'l details:
Is the patient on oxygen?
Yes (liter flow if known)   No		Add'l details:
Is the patient on intravenous fluids?
Yes (type if known i.e. hydration only or with medications)   No		Add'l details:
Is the patient taking pain medication?
Yes (liter flow if known)   No		Add'l details:
Patient Location Information:
Traveling from: home   skilled nursing facility		rehab center   acute care hospital
Name of facility: (City, State, Country)
Admission date:	Anticipated discharge date:		Travel date:
Traveling to: home   skilled nursing facility		rehab center   acute care hospital
Name of facility: (City, State, Country OR To be Determined)
Please offer any additional information: (i.e special needs or equipment, companions, current travel plans)