You will need to complete the following the following forms and send them to the VPA:

• Request for transportation questionnaire (pdf)
• Waiver of liability (pdf)
• Physician's statement (pdf)

The last two forms need to be mailed, with your handwritten signature. However, you can fax the request form (or complete the online version), so we can begin planning the mission.

You can reach us at this address.

Please fill in the appropriate information, so we can start planning the mission. You will also need to download the waiver of liability and physician's statement forms and mail them to us signed. Thank you!

Mission Information

Request by: Date:     Title: Phone: Fax: Phone at destination:             From city: State:     To city: State:     Hospital/Clinic: Phone:      Appointment date:   Appointment time:     Flight date:   Return date:     (blank if return transport not needed)

Patient Information

Name Age  Weight         Address: City: State:  Zip:         County: Phone:     Medical Condition: Communicable     Oxygen required Companion 1: Age  Weight         Companion 2: Age  Weight

Doctor Information

Name: Hospital/Clinic: Address: City: State:  Zip:         Phone: Fax:     Mobile: Pager:

Miscellaneous Information

If you have any further information or comments, please let us know: