GROUND DISPATCH

Birmingham
205.933.1911

Chattanooga, TN*
423.499.9500

Knoxville, TN
865.637.1800

Mobile, AL*
251.338.3338

Nashville, TN*
615.724.1911

Santa Rosa, FL
850.983.5372

For Emergency Dial 911
*Wheelchair service available

close >

AIR DISPATCH

Toll Free
1-800-262-4688
or 850-473-6776

close >

Request a Quote

Please complete the form below. All information will be kept strictly confidential and is intended solely for the purpose of determining the best mode of transportation and patient care requirements. Every attempt will be made to reply immediately to your requested quote. If you don not receive a response within 30 minutes, please contact 855-474-2477 and ask to speak to a Flight Coordinator. * denotes required fields

Your Contact Information
*Your Name	Your relationship to the Patient?

*Email Address	*Home Phone Number

How did you hear about us?	Work Phone Number

	Cell Phone Number


About the Patient
*What is the Patient's Diagnosis / Medical Condition?


*Patient's Age	*Patient's Weight


*Is the patient currently in the hospital? No Yes
Is the patient on a ventilator? No Yes
What is the patient's condition? Stable Unstable Critical

*Where is the Patient Now? (facility - city - state - country)

*What is the destination?

*What is the proposed travel date?
(mm/dd/yyyy)

Special Needs and Requirements
Is the patient on oxygen? No Yes
Does patient have any health insurance? No Yes
Does the patient have any IV's? No Yes
Is patient on life support? No Yes

Please describe any special equipment needs (ie: Ventilator).