Consult an AMAS Physician » Individual Confidential Questionnaire

Individual Confidential Questionnaire

Our board certified aerospace medicine physicians are standing by to answer your questions! As a confidential service, we only require a minimal amount of information to process your inquiry. The required fields are identified with an asterisk (*). All other fields are optional. Once submitted, your credit card will be charged our service fee of $49.95 and a physician will respond within two business days. Telephone access is also available at 1-866-AEROMED (1-866-2376633) for a service fee of $70.

Current members can contact AMAS by selecting Consult an AMAS Physician.

Name
First Last
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Fax
E-Mail*
Enter Email Confirm Email
DOB
Medical Class
- 1st
- 2nd
- 3rd
Heard about AMAS*
Question*
Total
$0.00
Credit Card*

American Express
Discover
MasterCard
Visa
Card Number Expiration Date Security Code Cardholder Name
Total
Name
This field is for validation purposes and should be left unchanged.

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Individual Confidential Questionnaire