Request a Quote for Air Ambulance Services

Contact person

Company

Phone

Fax

E-mail

Expected mission start date

Expected mission start time

Patient location

Destination

Sea level flight

Double stretcher

Additional person (e.g. relative)

Date of birth or age

Weight (kg)

Height (cm)

Width > 60cm (if available)

Main diagnosis

Concomitant disease(s)

Current treatment (ventilation drugs oxygen etc)

Infectious disease

High-risk pregnancy

Pediatric patient

Psychiatric disease

Terminal patient

Traction device

External pacemaker

Incubator

Intracranial pressure monitor

Other special devices

Security Code

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This form collects your name and email so that we can correspond with you. Check our privacy policy for more information. For data protection, please do not include the patient's name in this request.