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Info
First Name:*	A value is required.
Last Name:*	A value is required.
Caller's Relationship to Patient:*	A value is required.
Caller's Phone Number:*	A value is required. (###) ###-####Invalid format.
Email:*	A value is required.Invalid format.
Patient Name:*	A value is required.
Gender: (M,F)
Patient's Age:*	A value is required.Invalid format.
# of Passengers:	A value is required.
Origination
From City:*	A value is required.
From State:
From Country:*	A value is required.
Sending Facility Name:*	A value is required.
Destination
To City:*	A value is required.
To State:
To Country:*	A value is required.
Receiving Facility Name:*	A value is required.
Transport Date:*	A value is required. mm/dd/yyyyInvalid format.
Additional Information:

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December 10, 2009

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**Angel MedFlight is in the business of arranging air medical transportation services, commercial medical escorts, ground ambulance services and discretionary insurance benefit assistance. Angel MedFlight's focus is performing these obligations in a manner that far surpasses our customers' expectations.

Angel MedFlight utilizes the services of sole and exclusive FAA F.A.R. Part 135 vendors, such as Aviation West Charters (License Number: 4WCA069N).