at this moment 21626 wishes fulfilled with 1647 beautiful stories
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NL61 RABO 0112 9246 11. RABONL2U

Intake form

If you have a wish for a terminally ill patient who is immobile and dependent on transport by ambulance, you can fill in the intake form and define this wish as clearly as possible. Provide the full address where you want the patient to be picked up and also the address where (you and) the patient would like to go. Stichting Ambulance Wens will then contact you as soon as possible. If the wish needs to be realized at short notice you may be called back the very same day, so please ensure that you can be reached by telephone! Before filling in a form, think carefully about the following: what exactly is the patient’s wish, what date would suit best for this wish, what time would you like the patient to be picked up.

We kindly ask you as the contact person to note down a telephone number on which we can contact you between 08:00 and 17:00 hrs.

Stichting Ambulance Wens fulfills all wishes for free, but we would highly appreciate if you would send us afterwards a brief report of the wish fulfilled. These stories provide insight to our donors as to how we fulfill wishes, and other people can read about the range of possibilities.

If you have any further questions, please call us at +31 854444288.

Your wish

About the patient

Please fill in below the address where the patient should be collected:


About the contact person / person who submits the wish

About the treating physician

Other information


By submitting this completed form you consent to your personal data being used by Stichting Ambulance Wens for realising the last wish. These data will be kept in the archives of Stichting Ambulance Wens for 7 years.


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