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Published by admin, 2018-01-02 17:14:34

Sky Nurses Client Preparation Booklet

Client Case Book (1)

Case # ____________

(Sky Nurses Trip # ____________)

Sky Nurses

6530 W Rogers Circle
Suite 31
Boca Raton, FL 33487
Phone: 866-611-8434
Fax: 866-633-4188
Email: [email protected]

Table of Contents

Airline Information Confirmation …………………………………………………………3
Ground Information Confirmation ………………………………………………….……5
Medical Information Confirmation ……………………………………………………….7
About Hotels ……………………………………………………………………………………………..8
Additional Information ……………………………………………………………………………8
Fit to Fly Form ……………………………………………………………………………………………9

2

Airline Information Confirmation

Sky Nurses is proud to announce that our Travel Department has now doubled in
size! This means that Sky Nurses’ team of travel agents is always available to
book tickets whenever necessary.

Will Sky Nurses be booking the airline tickets for this mission or will the client be
providing tickets?

If Sky Nurses is booking tickets: Please fill out the following questionnaire.
Please note that without the information requested, we cannot reserve and book
tickets.

Patient Name: _________________ _________________ _________________

Surname Middle name (if applicable) Given name

Date of Birth: _______________ ____ ________

Month Day Year

Passport Number: ______________________________________

Country of Passport: _____________________

Country of Citizenship: _____________________

Companion Name: ________________ ________________ ________________

Surname Middle name (if applicable) Given name

Date of Birth: _______________ ____ ________

Month Day Year

Passport Number: ______________________________________

Country of Passport: _____________________

Country of Citizenship: _____________________

Class of Seating Desired: Economy Premium Economy Business

Companion Name: ________________ ________________ ________________

Surname Middle name (if applicable) Given name

Date of Birth: _______________ ____ ________

Month Day Year

Passport Number: ______________________________________

Country of Passport: _____________________

Country of Citizenship: _____________________

Class of Seating Desired: Economy Premium Economy Business

3

If the client will be booking tickets: Please provide us with the itinerary for
the patient and clinician as soon as it is confirmed. Please also provide the PNR or
confirmation numbers of all passengers in the party. This will allow the Sky Nurs-
es team to relay all information to the clinician swiftly in the event of a sudden
change in itinerary.

Patient PNR / Confirmation Number: _____________

Companion PNR / Confirmation Number: _____________

Companion PNR / Confirmation Number: _____________

Flight Itinerary

From Date Time To Date Time Airline/ Layover
(airport) (airport) Flight #

Clinician
Outbound

Clinician
W/Patient

Clinician
Return

Please note that we will need confirmation of all travelers’ identification. If Sky
Nurses is not booking the airline tickets, a copy of both patient’s and companions’

passports will still be requested for reference during the mission.

4

Ground Information Confirmation

Who will be booking the ground transportation for this case?

If Sky Nurses is booking ground transportation: Please complete the
following form so that we can provide appropriate and comfortable ground
transportation for the patient and their family.

Number of passengers: ________

(Includes patient, clinician, and all companions)

Type of vehicle recommended for patient: ___________________________

Will an additional sedan be required for companion/s? Yes No

(Recommended for parties over 2 with a BLS ambulance, or parties over 4 for other vehicles.)

Pick up address for patient: ______________________________________

____________________________________________________________

Room Number: ________

Phone number: _________________________________________

Hours of operation (if applicable): __:__ - __:__

Drop off address for patient: _____________________________________
____________________________________________________________
Phone number: _________________________________________

Luggage Information: Please list all luggage within the travelling party.

Large luggage: ____ Medium luggage: ____ Carry-ons: ____ Personal: ____

(Up to 76 cm x 48 cm, (Up to 67 cm x 45 cm, (Up to 48 cm x 32 cm, (Backpacks,

or 30 in x 19 in) or 26 in x 18 in) or 19 in x 13 in) purses, etc.)

Special Instructions (if applicable):
_____________________________________________________
_____________________________________________________

5

If the client is booking ground transportation: Please provide us with
the following so we can brief the clinician. If the clinician will be taking a taxi
for any portion of this itinerary, please indicate below.

Event Type of vehicle/ Estimated pick Driver name /
company
up time phone number

Clinician arrival at air-
port to patient’s loca-
tion or hotel

Clinician to hotel (if

Clinician from hotel to
patient’s location on
date of departure

Clinician and patient to
airport
Clinician and patient to
patient’s destination

Clinician back to the

6

Medical Information Confirmation

Please provide us with the following medical information so our medical department
can advise our clinicians accordingly.

Diagnosis:

Date of Birth:

Gender of clinician preferred:

Level of clinician preferred: Nonmedical Paramedic RN Physician

Are multiple clinicians needed? No Yes, ____ clinicians

Can the patient

Sit up during take off and landing? Yes No

Stand? Yes With assistance No

Walk? Yes With assistance No

Climb stairs? Yes With assistance No

Does the patient require Oxygen on the ground? No Yes, ___ LPM

Does the patient require Oxygen during flight? No Yes, ___ LPM

Will the patient require special seating? No Yes, ___________________

Additional comments regarding the patient’s condition: _____________________

_________________________________________________________________

7

About Hotels

When possible, Sky Nurses prefers to book hotels for our clinicians.
We do this to ensure that all hotel rooms booked are prepaid before
the clinician’s arrival. If you would prefer to book the hotels for our

clinicians, please ensure that they are paid in full prior to the
clinician’s arrival. Please also provide Sky Nurses with the name,
address, phone number, and confirmation number of that hotel.

We appreciate your cooperation in this matter.

Additional Information Page

If there are additional factors not yet covered that we should
consider while building your trip, please list them here:

________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

8

I, _________________________________________, (MD, DO) licensed to practice medicine in the country

of __________________________, certify that ________________________________is a patient under my
care. At the time of discharge, it is my professional judgment that this patient is physically able to safety
complete a commercial airline flight to _______________________ with a Medical Escort. I further certi-
fy that the above-mentioned patient does not have a disease or infection that can be transmissible to other per-
sons during the normal course of the flight.

ate Fit-to-Fly: ___________________
Patient Name: __________________________________________
Admission Date:
__________________________________________________________________________
Discharge Date: __________________________________________________________________________
Diagnosis at Discharge: ____________________________________________________________________

Prognosis for the Journey: Good Fair Poor
Type of Escort: Paramedic Registered Nurse Physician
Equipment Needed: Portable Oxygen Concentrator Cardiac Monitor/AED Nebulizer Suc-
tion

Physician Orders
_________________________________________________
_________________________________________________
_________________________________________________

_________________________________________ ____________________________________
Physicians Signature Date of Signature

9


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