Patient Application - Wings of Mercy

Your Information

For the fields below, please information about yourself, not the passenger (unless you are the passenger).

Your Name(Required)

First Last

Your Email(Required)

Phone(Required)

How did you hear about us?

Passenger Information

For the fields below, please enter information about the passenger who would be flying with us.

Your Relationship to the Passenger(Required)

Passenger Name(Required)

First Last

Passenger Address(Required)

Street Address Address Line 2 City State ZIP Code

Passenger Contact Phone(Required)

Passenger Gender(Required)

Passenger Birth Day(Required)

Passenger Height(Required)

Please enter in feet and inches. (ex. 6'2").

Passenger Weight(Required)

Please enter the passenger's weight in US pounds. Pilots require this information in order to calculate fuel for the flight.

Ability to Move(Required)

Normal - Can walk or climb without assistance

Limited - Can walk and climb with assistance

Restricted - Can walk with assistance but not climb

Wheelchair - Must be lifted into aircraft, cannot walk but can sit upright in aircraft seat

Recumbent - Must be lifted into aircraft, cannot sit upright

Stretcher - Must be lifted into aircraft on stretcher, cannot sit upright

Choose the highest level of mobility which is safe for this person.

Emergency Contacts

At least one emergency contact is required.

Emergency Contact 1(Required)

First Last

Relationship(Required)

Phone(Required)

Email(Required)

Emergency Contact 2

First Last

Relationship

Phone

Email

Flight Information

Departure Date(Required)

Return Date

Preferred Departure Airport

Preferred Destination Airport

Departure State(Required)

Destination State(Required)

In order to quality, you must have a departure location or destination within Michigan, Wisconsin, Indiana, Illinois, or Ohio

In order to quality, you must have a medical need for long distance transportation East of the Rocky Mountains.

Flight Companion Information

Wings of Mercy requires that you have a companion fly with you.

Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Flight Companion Height(Required)

Please enter in feet and inches. (Ex. 6'2")

Flight Companion Weight(Required)

Please enter the flight companion's weight in US pounds. Pilots require this information in order to calculate fuel for the flight.

Form Completion

Signature(Required)

By signing below, I affirm that I have read all forms and am aware of restrictions and limitations of a Wings of Mercy flights. I also understand that Wings of Mercy may use photos from flight, and I may call or write to request to opt out of photos.

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Flight Application

Your Information

Passenger Information

Emergency Contacts

Flight Information

Flight Companion Information

Form Completion