Patient information First name Last name Pesel number (non Polish resident - numer passport number) Citizenship Patient's city of residence Street Building number Apartment number Postcode Patient's phone number (optional) Check the box if the data of the payer / ordering party are different than the patient's Payer information Payer's first name Payer's last name Payer's pesel number (non Polish resident - numer passport number) Payer's citizenship Payer's city of residence Street Building number Apartament number Postcode Payer's phone number E-mail address Informations about transport Date of the transport YYYY-MM-DD Time : Pickup address Country City Street Building number Apartament number Postcode Additional information (optional) Destination address Country City Street Building number Apartment number Postcode Additional information (optional) Patient's condition and medical diagnosis Medical documentation Additional information about transport and personal belongings to take (optional) I consent to the processing of the provided data for the purpose of handling the order I accept the terms of the transport contract set out below. This contract reffers to the service of medical transport by ambulance with the crew, offered to the Ordering Party by NORD AMBULANSE for the price specified in the offer. The condition for booking the medical transport service is sending this order and confirmation of payment by e-mail to kontakt@nordambulanse.pl Cancellation fees: Up to 72h before the team's departure -30%, 72h - 24h before the departure -50%, less than 24h or "no show" is -100%. All changes to the schedule or itinerary must be confirmed in writing by the Customer and may result in a price change.
