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. This fee is good for two (2) days and allows for follow up questions to your original request.

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
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

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Individual Confidential Questionnaire