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Air Medical Transport

Secure Payment Form

Trip Reference Number
Date of Transport
Patient's First & Last Name
Service Type Requested
Order Amount in USD
Convenience Fee (4%)
Total Amount
Name as on Card
Card Number
Card Expiration Date
CVV2/CID
Card Billing Address
Card Billing Zip
Do you want Air Medical Transport, to securely store your payment and contact information for future recurring cases or transports?
Company Name
First & Last Name
Phone Number
Email Address
Your Initials

I accept and agree with the General Terms and Conditions of Air Medical Transport and with the processing of my personal data in accordance with the Privacy Statement of Air Medical Transport. Please note that a 4% convenience fee is added to every transaction.