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Physician’s Evaluation Form
PATIENT INFORMATION:
Patient's Name
*
First
Last
Age
*
Sex
*
Weight
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Patient’s medical diagnosis and reason for travel:
*
NOTE THIS FORM MUST BE SUBMITTED TO PFC DIRECTLY FROM THE PHYSICIAN’S OFFICE
Physician Name:
*
First
Last
Physician Email:
*
Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone
*
Medical reason for requested travel: Please check the box(es) that apply.
*
Time-Critical (Need for travel in the next 24 hours or as soon as possible)
Compassion (physically unable to travel by any other means)
Low Immunity System
Other, please explain:
Please Note: Pilots for Christ, Inc. is not an air ambulance service and will not able to provide any medical attention before, during, or after the flight. We cannot accept an application if the person requires any life support equipment, incubator, etc. although wheelchair may be accepted. Please list any special equipment needed by this patient during flight (if any):
Does the patient’s condition require this form to be updated?
*
Yes
No
If so, how often?
To the best of my knowledge, this patient/family is eligible for charitable transportation. I am sufficiently familiar with aviation physiology to be of the opinion that this patient can travel in small aircraft at ambient pressure altitudes up to 11,000 feet above sea level, and that said patient has no need of medical assistance before, during, or after the flight.
Print Name:
*
Signature
*
Clear Signature
M.D./D.O. Date:
*
Name
Submit
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