EmailMe Form - Request for Consultation

Name of Medical Transport Service *
Mailing Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region
Web Site
Principle Contact *
First Last
Title
Email *
Phone
### - ### - ####
Type of Consult Requesting *
Documentation Review ($1000)
On-site Visit (see below if this is your option)
On-Site Visit ($3000 [$4000 international] for first day, $1000 for each additional day + expenses billed after visit)
Requested Time Frame (month)
How many days are you requesting?
Name and Address of Hospital (if hospital affiliated)
Total number of bases
A base is defined as any place aircraft/ambulance and medical crew are located.
Description of Service
(Check all that apply to your service)
Types of Service
RW (ALS)
RW (Critical Care)
FW (ALS)
FW (Critical Care)
Ground (ALS)
Ground (BLS)
Ground (Critical Care)
Medical Escort (Basic Care)
Medical Escort (Advanced Care)
Transports Request Accepted

RW FW G ME

Burns

Cardiac

IABP

Trauma

Pediatric (PICU)

High Risk OB

Adult

Neonatal
Size of the Service
(Dedicated aircraft/ambulance(s) are used for more than 1 transport per month for any consecutive six month period)

RW FW G ME

Total number of transports in most recent fiscal year

Total number of dedicated aircraft/ambulance(s)
RW FW G ME

FAA Cert #

Company Name/Owner/Operator

Address
Any added information you'd like for us to know.
Office Use Only
Added to Checklist

	RW	FW	G	ME
Total number of transports in most recent fiscal year
Total number of dedicated aircraft/ambulance(s)