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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 First 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. Invalid Email.

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. in the comments box below.

Earliest Possible Travel Date (To Treatment) *

Earliest Possible Travel Date required.

Latest Possible Travel Date (To Treatment) *

Latest Possible Travel Date required.

Earliest Possible Return Date (From Treatment) *

Earliest Possible Travel Date required.

Latest Possible Return Date (From Treatment) *

Latest Possible 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 registering. 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.

107 Mill Plain Road
Suite 204
Danbury, CT 06811

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Patient Inquiry Form

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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. in the comments box below.

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