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American Family Children's Hospital
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Hospital Request for Med Flight Educational Presentation or Helicopter Visit

UW Health's Med Flight program is proud to be partners in emergency critical care and transport with fire and EMS programs and surrounding hospitals in Wisconsin, Illinois, Iowa, Michigan and Minnesota.

 

Med Flight staff provides training in safety around the helicopter and preparing a specific type of patient for transport, as well as best practices for optimal patient outcomes. Or, if your facility is holding a specific event and you would like Med Flight to attend, complete this form.

 
 
Date and Time Requested
 
Hospital Name
 
We are requesting:
 
Education (list details below)
Lecture (list details below)
Event (list event name/details below)
 
Topics for Education/Lecture and/or Name of Event
 
Contact Person
 
Contact Phone Number (mobile number preferred)
 
 
Number Attending
 
 
CONTACT INFORMATION
 
Name
 
Phone Number
 
 
 
DAY OF CONTACT INFORMATION (if different from above)
 
Name
 
Phone Number
 
 
Event
 
 
Details/Other Information
 
Requesting helicopter to attend?
 
Yes
No
 
 
Address of Landing Zone (please list any cross roads)
 
Agency Securing Landing Zone
 
 
 
 
OFFICE USE ONLY
 
Follow Up
 
Date Verified
 
 
By
 
Map and Coordinates Printed
 
 
Added to the Calendar