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Physician’s Evaluation Form

PATIENT INFORMATION:
NOTE THIS FORM MUST BE SUBMITTED TO PFC DIRECTLY FROM THE PHYSICIAN’S OFFICE
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):
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.