Transport order

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

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.

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