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 (M/D/Y)
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? (M/D/Y)	*
What is your preferred date of your Return Flight? (M/D/Y)
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:	(M/D/Y) * (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?	*
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 reserves the right to refuse any flight request at its sole discretion.	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 *