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Assistance Request Form

Please be aware that flight requests can only be fulfilled with a minimum of 21 days from the appointment date to ensure adequate time to receive necessary paperwork and schedule the flight.
Please do not submit requests with less than 21 days notice as they will not be accommodated. We do not provide any flights outside the United States. Veteran status verification required. This program does not provide any compassion flights for family members without the patient present.

Veteran's Information

Branch of Service*

Status*

State*


Nature of Request & Reason for Travel*

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Travel Information

Appointment time *

One Way or Round Trip *

 One Way  Round Trip 

Departure Time *

Return Time *

If your request contains more than one destination, please provide details in the 'Nature of Request' section

Departure

State*

Destination

State*

State*

Personal Physician Information (Your primary Physician. This is the physician who will provide your medical release, so they should be the physican most familiar with your current condition.)

Treating Physician Information (Physician you are traveling to see)

Passenger Data

Please include all travelers, including Service Member, if applicable

Is the Service Member listed above traveling as a passenger?

 Yes  No 

Passengers' Legal Names (As appears on Gov't issued ID)

Add third passenger

Verification Information

Please provide the contact information of someone who can verify your request





Relationship*

Special Requests

Please detail any special needs you might have while traveling (service animal, wheelchair assistance, extra time between flights, etc).

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IMPORTANT: I authorize Angel Airlines for Veterans to contact my physician through the information I have provided to obtain a medical clearance form showing proof of appointment:

 Yes  No 

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