top of page

Patient/Parent/Guardian of Patient 

Click the link below to view, fill and sign our waiver

Request Our Services

Flying Wings of Louisiana is always eager to help those who are in need. Fill out the form with the important information we need and we’ll contact you as soon as possible!

Requestor's Information

Flight/Mission Information From:


Patient's Appointment Information

Patient Information (weight limit per person is 250 lbs.)

Patient's Weight (weight limit is 250 lbs.)

Patient's Emergency Contact Information

Companion's Information (Due to weight limits, only one companion is allowed.)

Companion's Weight (weight limit is 250 lbs.)

Doctor's Information

Miscellaneous Information

If you have any further information or comments, please let us know:

Thanks for submitting!

bottom of page