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For a specific medical transport inquiry,complete the: Transport Inquiry Form
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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. "I don't know" for any uncertain responses. Anticipate a timely response.
Inquire About a Transport

Your First & Last Name.

Your Email Address.

How did you hear about Flying Nurses International?

Contact Information
Please fill out at least one phone number and your time zone.







Patient Information

The patient's first & last name.

What is your relationship with the patient?

How old is the patient?

How much do they weigh?

Diagnosis and Brief History of Current Medical Condition


Can the Patient Stand?
  • Ambulates
  • Partially with Assistance
  • No (Full Lift for Transfer)


Additional Details:


Can the Patient Sit Up?
  • Wheelchair
  • Reclining Bedside Chair



How long can the patient sit?
Additional Details:


The Patient is on Oxygen
The Patient is on Intravenous Fluids
The Patient is Taking Pain Medication


Travel Information
Traveling From:
  • Home
  • Skilled Nursing Facility
  • Rehab Center
  • Acute Care Hospital



Enter the Facility's Name, City, State, Country.


Traveling To:
  • Home
  • Skilled Nursing Facility
  • Rehab Center
  • Acute Care Hospital



Enter the Facility's Name, City, State, Country.



What date was the patient admitted to their current facility?

What is the anticipated date of the patient's discharge?

What is the date of travel?


Additional Comments

Please offer any additional information: (i.e special needs or equipment, companions, current travel plans).


Security Code

Please enter the code shown above.
 

*Flying Nurses International is not affiliated or otherwise associated with InteliStaf or its "Flying Nurses" travel nurse staffing division.*

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