Lifeguard International - Emergency Ambulance and Air Transportation Services

Request a Free Quote Please complete the form below. All information will be kept strictly confidential and is intended solely for the purpose of determining the best mode of transportation and patient care requirements. Every attempt will be made to reply immediately to your requested quote; however, it may take up to 48 hours to receive a response. For immediate attention phone 1-800-262-4688 and ask to speak to a Flight Coordinator. * denotes required fields

About the Patient
*What is the Patient's Diagnosis / Medical Condition?


*Patient's Age	*Patient's Weight


*Is the patient currently in the hospital? No Yes
Is the patient on a ventilator? No Yes
What is the patient's condition? Stable Unstable Critical

*Where is the Patient Now? (facility - city - state - country)

*What is the destination?

*What is the proposed travel date?
(mm/dd/yyyy)

Special Needs and Requirements
Is the patient on oxygen? No Yes
Does patient have any health insurance? No Yes
Does the patient have any IV's? No Yes
Is patient on life support? No Yes

Please describe any special equipment needs (ie: Ventilator).


Your Contact Information
*Your Name	Your relationship to the Patient?

*Email Address	*Home Phone Number

How did you hear about us?	Work Phone Number

	Cell Phone Number