Hope Air - About Us

* required fields

Who is making this Flight Request?
Do we contact you or the Client for more information?
Your name	*
Your phone number	*
Your email address
Your relationship with the Client (person who needs our Flight)	*
Information about who needs our assistance
Salutation	*
First Name	*
Last Name	*
Birthdate (MM/DD/YYYY)	*
Home telephone number	*
Cell phone number
E-mail address
Current Address
Street Address	*
City	*
Province	*
Postal Code	*
What is your Language Preference?	*
Information about the Flight you are looking for
What is your preferred Departure City?	*
What is your preferred Arrival City?	*
What is your preferred date of your Flight Departure? (MM/DD/YYYY)	*
What is your preferred date of your Return Flight? (MM/DD/YYYY)
Information about your Doctors
Tell us about the Doctor who has recently seen you and who we can call to confirm that you are medically able to fly:
Doctor First Name or initial	*
Doctor Last Name	*
Telephone #
Fax #	*
Tell us about the Doctor you are flying to see?
Doctor First Name or initial	*
Doctor Last Name	*
Telephone #	*
Information about your Medical Appointment
What is the Date and Time of the Appointment(s) you are flying to:	(MM/DD/YYYY ) * (eg. 2 p.m.) *

What is the name of the Treatment Centre you are going to?	*
What type of illness do you suffer from and for which this appointment is for? (e.g. Cancer, Lung)	*
What is the reason for this medical trip:	*
Other Important Information we need
Do you require an escort to accompany you on this trip?(I am not capable of traveling independently for medical reasons. Hope Air will verify with your doctor.)	*
If yes, please provide us with the name and contact information of your proposed medical escort:
First Name
Last Name
Address
How did you hear about Hope Air?	*
I confirm that the information provided in this Form is accurate.	Check to agree *
I confirm that the cost of the needed medical treatment is being covered by my provincial health plan.	Check to agree *
I understand that I am only making a request for a flight, not a confirmed booking, and that Hope Air serves Clients in financial need who are unable to afford the costs of an airline ticket. We will follow up with a phone call to obtain financial details for your household. I consent to providing this information.	Check to agree *
I understand that Hope Air will call my doctors, and I give permission for such, to confirm my ability to fly and the date and time of my appointment.	Check to agree *