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Fields marked with an * are required.
UNOS number:
*
Organ(s):
*
Heart
Lungs
Liver
Split Liver
MVT
KP
Pancreas
Intestine
Kidney
Other
DCD/BD:
*
BD
DCD
NRP DCD
Accepting transplant or research center:
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Organ procurement organization:
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Box run or team onboard
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Box run
Team onboard
Number of passengers:
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0
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Additional supplies onboard:
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None
Organ Box
Perfusion Device
Pick-up airport code or name:
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Requested fixed-based operator (FBO) for pick-up:
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Destination airport code or name:
*
Requested fixed-based operator (FBO) for destination:
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Requested landing and/or standby date
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Requested landing and/or standby time:
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Time zone:
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Central Time
Eastern Time
Mountain Time
Pacific Time
Transit time in minutes from donor hospital to airport:
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OR Date
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Local OR time:
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Time zone:
*
Central Time
Eastern Time
Mountain Time
Pacific Time
Routing with explanation of each leg:
*
Any additional comments (such as inquiries about specific aircraft or known cross clamp delays):
First name:
*
Last name:
*
Phone number:
*
Email address:
*
Requestor's organization:
*
I acknowledge that all requests are on a first-come, first-serve basis and I do not have a confirmed flight until a trip sheet is returned to me.
*
If you are a human seeing this field, please leave it empty.
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