Medical Evacuation Readiness Declaration
Patient Name
Patient ID / Reference Number
Date of Request
Location / Facility
Diagnosis / Reason for Evacuation
Attending Physician
Current Medical Condition
Required Medical Support During Evacuation
Receiving Facility (if known)
I hereby declare that the above patient is ready for medical evacuation and all necessary preparations have been made according to medical protocols.
Physician Name
Signature
Date
Facility Representative Name
Signature
Date