Unsere Partner
Request form
Important information:
In an emergency, please contact us immediately by phone or fax.
Tel.: +49 (0)228 230023
Fax: +49 (0)228 230027
The information marked with an asterisk (*) is mandatory. GRC Air Ambulance Service needs it to respond to your request for help. Please fill out the form as completely as possible.
1. Who is calling?
Last name*
(Erforderlich)
First name*
(Erforderlich)
Company / Organization / Agency
Landline and / or cell phone*
(Erforderlich)
Email
Further availability
2. Who is ill / injured?
Last name*
(Erforderlich)
First name*
(Erforderlich)
Birth name
Age / Birth date*
(Erforderlich)
Address in Germany:
Street
Number
ZIP
City or town
Current contact address:
Location*
(Erforderlich)
Country where located*
(Erforderlich)
3. Where is the ill/injured person already receiving medical treatment?
Name of hospital
Address of hospital, department / ward / room
Name of treating physician*
(Erforderlich)
Phone of physician*
(Erforderlich)
What language does the physician speak?*
(Erforderlich)
Remarks
4. What happened? How can we help you?
Please describe briefly the type of injury/illness and the on-site situation:
5. Who pays for the hospital expenses?
in foreign country
in Germany
6. Are you or the patient a member of the German Red Cross?
Last name
First name
(District) Chapter
Membership number
Information:
This request does not justify an assignment for GRC Flight Ambulance Service.
Send request:
Please check all entries to ensure they are correct.
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