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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 (Please note, we require a 10 business day lead time) *

Appointment Date required.

Flight Support Needed*

To Treatment

From Treatment

Roundtrip

Please select any of the Flight Support Needed.

You can never use our services up, we do just ask that we take one appointment request at a time.

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 Comments

Thank you for your online inquiry. A member of the CAN team will reach out within 24 business hours. To help us assist you efficiently, please have the following information ready:

The doctor’s name and phone number of the office you are traveling to.
The name, phone number, and fax number of any medical provider the patient has seen in the past 30 days to determine medical clearance for travel.
If traveling to MD Anderson, we will also need the patient’s medical record number.
Please note: Submitting this form does not confirm your request for a flight.

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

You can never use our services up, we do just ask that we take one appointment request at a time.

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