UKRAINE EVACUATION FORM

EVACUATIONS OF PERSONS BASED ON IMMEDIATE MEDICAL CONDITIONS OR SECURITY RISK SITUATIONS.
EVACUATION REQUEST FORM
Please submit this form for each individual.
Valid and in date passport in hand
Medical Questions
Do you require medical evacuation or Medical Services with your evacuation request?
Do you have any medical problems?
Do you take insulin or suffer with seizures/epilepsy?
Do you take any blood thinner medication such as aspirin, low molecular weight heparin (LMWH), Warfarin or others?
What is your blood type?
What is your blood type?
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