:: LIFEFIRST MEDICAL SERVICES ::

For Activation of Ambulance Services

Type the number in the
box provided:

Road Ambulance
Air Ambulance
Other

Please Contact Me:

By email only - do not call
By telephone within
24 hours

Approximate Travel Date:

ASAP Within the next 72 hours
Within the next week
Within the next 30 days

Unknown Name:
Relation to Patient:
Home Phone:
Mobile Phone:
Email:
Address:
Location of pick up
Time of pick up
Destination City:
Destination State:
Medical Condition of Patient:
Any Other Information: