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Ambulance Services Request
Name/Organization *
Email *
Phone *
Needed Services *
Please choose
Event standby
Transfers
Pickup *
Dropoff
Contact person (on site) *
Contact person phone (on site) *
Event date
Event Time
Current situation
Patient is unconscious
Patient is bleeding
Patient needs oxygen
Personnel needed
Nurse only
Doctor only
Ambulance with nurse
Ambulance with doctor
Ambulance with nurse & doctor
Number of participants
Just one person
5 - 20 persons
20 - 50 persons
50 - 100 persons
More than 100
Message
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