Patient InformationFull Name *Date of Birth(BS) *Select Gender *GenderMaleFemaleNot to specifyMobile No *Email IDAddress *CityEmergency Contact InformationContact Person *Relation *Mobile No *Medical InformationDiagnosis *Date of Diagnosis (BS) *Current Stage of Cancer *Treatment Plan *Current Consulting Doctor *Registration Number *Name of Hospital/Institute Currently Treating PatientRequired DocumentsConfirmation Report *Choose FileNo file chosenDelete uploaded fileA medical certificate from the treating oncologist confirming the cancer diagnosis and stating the necessity for treatment.Identity *Choose FileNo file chosenDelete uploaded fileA copy of the patient’s government-issued ID (e.g., passport, Citizenship card).Referral Letter (If Applicable)Choose FileNo file chosenDelete uploaded fileTravel ApprovalChoose FileNo file chosenDelete uploaded fileA letter from the treating doctor stating that the patient is fit to travel.Health Services and Accommodations RequestsMedical Assistance *Oxygen SupportWheelchairMedical Escort(Doctors/Nurse)Special Assistance(if applicable) *Flight InformationPreffered Date of Travel *From(City) *Declaration and Consent *I, the undersigned, hereby declare that the information provided above is true and accurate to the best of my knowledge and belief. I consent to Yeti Airlines and the Birat Cancer Institute to verify my medical condition with the hospital/treatment center and medical practitioner named herein. I understand that this information is collected solely for the purpose of verifying my eligibility for the free flight service provided by Yeti Airlines to cancer patients traveling to the Birat Cancer Institute.Submit
