| FROM |
|
| TO FAX NUMBER |
CNAS |
| Reference number | |
| Patient Name surname / Nom Prénom | |
| Age | |
| Transport required / Type de transport | |
| Diagnosis / Diagnostique | |
| Strecher / Civière | |
| Sitting case / Position assise | |
| Client to be collect from / Lieu prise en charge | |
| Adress / Adresse | |
| Transport to / Destination | |
| Date of travel/ Date du transport | |
| Flight reference-Company | |
| Departure time (Local) / Heure de décollage | |
| Travel companions/ Accompagnants | |
| Medical crw ( names) / Equipe médicale | |
| Any other arrangements / Autres, |