Request a Free Consultation | Compassionate Companion | Travel Care Services | Nurse Assistance for the Disabled or Elderly on Vacation

Your name:

Your Address:

City:

State:

Zip Code:

Your email address:

Retype email address:

Your Phone Number:

Best time to call:

Your relationship to the traveler:

Traveler's Information

Traveler's name:

Travelers address:

Traveler's age:

Traveler's gender:

Traveler's phone number:

Travel Information

Dates of travel:

Travel Destination(s):

Destination address (if known):

Departure airport:

Arrival airport:

Do you need airport shuttle service?

Is ground transportation needed?

Is a wheelchair necessary?

Any special handicap accomodations?

Companion gender preference:

Traveler's personal Information

Please describe your physical disability or chronic illness:

Are you able to walk?

If you can walk, how far can you walk?

Are you able to walk up limited steps

Do you use any mobility assistive devices?

Can you transfer into and sit in a regular seat on a plane/motor coach?

Smoking preference:

Do you have any dietary requirements?

If yes, please describe your dietary needs:

Additional comments:

Diagnosis of your loved one (traveler)

On Oxygen? Yes/No

Incontinence? Yes/No

Hearing Impairment? Yes/No

Vision Impairment? Yes/No

Medications:

Language:

Ethnicity:

Allergies:

Hobbies/Interests:

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25820 Orchard Lake Rd • Farmington Hills, MI 48336 • (248) 313-2275 • [email protected]

Compassionate Companion Travel Services, Inc. is nurse owned and operated.