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Fly for CAN | Patient Inquiry Form Donate

Patient Inquiry Form for Travel Within the United States

Please fill out the form below and a representative from Corporate Angel Network will reach out to complete your registration. Please note: this form does not confirm your request for a flight. Your request will be processed after a team member connects with you.

* Required Field

Patient Type*

New Patient

Existing CAN Patient

Unsure

Please select patient type.

Patient First Name*

First name required. Invalid Last name.

Patient Last Name*

Last name required. Invalid Last name.

Full Name (If not patient)

Relationship to Patient *

Please select Relationship to Patient.

Other Relationship Detail *

Other Relationship required. Invalid Other Relationship.

Contact Number*

Contact number required.

Contact Email*

Contact email required.

Treatment Center*

Treatment Center required.

Is the patient able to walk up/down aircraft stairs unassisted?*

Yes

Please select required

Does the patient require medical assistance (i.e. oxygen) while traveling?*

Yes

Please select required

Appointment Date *

Appointment Date required.

Flight Support Needed*

To Treatment

From Treatment

Roundtrip

Please select any of the Flight Support Needed.

Provide more detail on additional travel dates, i.e once a month, once every 6 weeks, etc. A Corporate Angel Network representative will discuss these additional needs with you.

Earliest Possible Travel Date *

Earliest Possible Travel Date required.

Latest Possible Travel Date *

Latest Possible Travel Date required.

Earliest Anticipated Return Date *

Earliest Anticipated Return Date required.

Latest Anticipated Return Date *

Latest Anticipated Return Date required.

Departure City*

Please add departure city.

Departure State*

Please add departure state.

Destination City*

Please add destination city field.

Destination State*

Please add destination state field.

Additional Travel Dates Needed*

Yes

How did you hear about us? *

How did you hear about us is required.

Additional Comments

Thank you for your registration.

Please note: this form does not confirm your request for a flight.
Your request will be processed after a CAN team member connects with you, which will be within the next 24 business hours.

Patient Inquiry Form for Travel Within the United States

Provide more detail on additional travel dates, i.e once a month, once every 6 weeks, etc. A Corporate Angel Network representative will discuss these additional needs with you.

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Patient Inquiry Form for Travel Within the United States

Provide more detail on additional travel dates, i.e once a month, once every 6 weeks, etc. A Corporate Angel Network representative will discuss these additional needs with you.

Thank you for your registration.

Please note: this form does not confirm your request for a flight. Your request will be processed after a CAN team member connects with you, which will be within the next 24 business hours.

Please note: this form does not confirm your request for a flight.
Your request will be processed after a CAN team member connects with you, which will be within the next 24 business hours.