Swift Air Pre-Flight Coordination Form

PATIENT DETAILS

Title
First Name
Last Name
Date Of Birth
Nationality
Passport Number
Date of Expiry
Weight
Height
Actual Status
Other Medical Details
Confirmation of Visa if necessary

DETAILS OF ACCOMPANYING RELATIVE (IF APPLICABLE)

Title
Sure Name
First Name
Date Of Birth
Nationality
Passport Number
Date of Expiry

RELEASING HOSPITAL

Name of Hospital
Address of Hospital
Name of Treating Doctor
Telephone No

RECEIVING HOSPITAL

Name of Hospital
Address of Hospital
Name of Treating Doctor
Telephone No

GROUND AIR AMBULANCE

Are you in charge of ground air ambulance ?
Ground air ambulance details at embarkment
Ground air ambulance details at disembarkment