Please fill out the form below and submit.
Please complete this information for the Patient or Primary Passenger who has a need for transportation. It is important that you provide a follow-up contact person for us to call to respond to your request. This may be a social worker, parent or yourself as the passenger.
Items marked with * are required entries.
Use Full Legal Name as appears on your ID Card
This is the address where your gas card will be delivered. An adult must be available at this address to sign for the delivery. We cannot deliver to a PO Box.
Please complete as much detail as possible about the Primary Passengers Travel request.
Passenger is traveling FROM
Passenger is traveling TO
How many trips will be required for your treatment?*
Please explain your travel plans/needs in detail below.*
Our program provides a round trip ticket for the patient traveling for treatment and one escort. If you are traveling with an escort please complete the following.
In order to further process your request for assistance we will need to know the gas station you prefer from the list of gas stations below. We can only provide gas cards from the list below.
Please choose your selections from the options below:
76 Arco BP Chevron Chevron Texaco Circle K Conoco Exxon Exxon Mobil Gulf Mobil Phillips 66 Shell Sinclair Speedway Sunoco Texaco WAWA
As each trip is a gift from a donor, it is important for us to understand the financial need and reason for requesting assistance.Please fill out a brief description in each box and answer the questions below to help us help you.
How did you hear about Us?
American Cancer Society
American Red Cross
Clergy or spiritual advisor
Friend or relative
National Patient Travel Center
Other social media
Referral agency (like 211)
Social worker or physician
Patient's primary illness/condition (briefly)
Cleft Lip and Palate
Integumentary - Skin and appen
PTS - Post Traumatic Stress
Rare Genetic Disorder
Financial Situation - Brief description of financial situation that warrants support
Reason for travel - Brief description of passenger's illness, diagnosis, or reason for needing assistance
Prior to coordinating a trip we must obtain a medical release from your personal physician. This physician must have seen you recently, be familiar with your
current medical condition, and be willing to attest to your ability to travel safely.
Personal Physician Information (Your primary Physician)
Please upload documentation verifying that you have a medical appointment at the facility specified above. Examples
include a letter from you physician, a printed appointment reminder from the physician's office, or a screen shot of the appointment
details from your online patient portal.*
Please upload documentation showing your household income. Examples include income tax forms, social security statements, or W2 forms.
Please choose the income bracket from the list below that best represents the patient's total, annual, household family income.*
Please the number of people living in your household.*
# of People in Household*
Please choose the ethnicity that best describes the patient.*
American Indian or Alaska Native
Black or African American
Native Hawaiian or other Pacific Islander
IMPORTANT: I authorize Angel Wheels to contact my physician through the information I have provided to obtain a medical clearance form showing proof of appointment: