Submit a wish

Do you have a wish?

Our aim is to make the impossible, possible, by providing the means to make a wish, however simple or complex, a reality. From the initial contact onwards, we arrange every aspect of the wish.

We welcome wishes big or small from everyone, adult or child. Nearly everything is possible and the service free of charge.

If you wish to use our service, or you know someone who has a last wish, then please complete our application form on the website and we will respond to you as soon as we can.

Submit a wish

What will happen?

The patient decides the day. We will come with a specially designed ambulance and qualified medical staff (an ambulance driver and a nurse) to accompany the patient during the wish. In addition, 2 more people can join the patient in the ambulance. Others come to join the wish by their own means of transport.

The ambulances are especially focused on comfort, with a soft mattress, pillows and a duvet. It’s equipped with shuttered windows so that you can look outside, enjoy the view but not be seen.

Please complete the application form. We will contact you as soon as possible.

Please fill out the form below and describe your wish as clearly as possible, stating the address where you would like to be picked up from and the address/destination you would like to go to. We will then look into the organisational aspects of your wish and will contact you as soon as possible. For us to do this, please provide all relevant telephone numbers on which we can reach you (between 8.30 and 17.00 hrs.) as well as an email address.

The Ambulance Wonsch fulfils all wishes for free. However, if you could include a brief account of your wish and the reasons behind it, we would like to share your story anonymously with our sponsors to generate more donations for the foundation in order to help others fulfil their wishes too.

By completing the form you consent to the information being shared with our carefully selected and trained volunteers. The information you provide will be kept securely and in accordance with current GDPR requirements.

Criteria and Conditions of Transport

Please read this section carefully prior to completing the application form. If you have any problems completing the form, please contact us by email at info@ambulanzwonsch.lu.

Criteria for the Provision of Wishes

We grant wishes to anyone who is bed-ridden and fulfils any of the below criteria — someone who, without the support of our specialist vehicles and volunteers, would not be able to fulfil their wish.

– Terminally ill
– Life debilitating illness
– Elderly at end-stage of life
– Requires assistance with the transportation of medical equipment to fulfil their wish, for example, ventilator, oxygen etc.

Carrying out the wish is free. We are a non-profit organization, aiming to fulfil every last wish, but are dependent on available resources and reserve the right to cancel or postpone a wish at any time.

Conditions of Transport

Patients must have the consent of their lead clinician for undertaking the proposed wish.

Therefore, please indicate the name and contact details on the application form. The clinic or their deputy need to be contactable for the duration of the wish (if required).

Patients must have enough and appropriate medicines and medical devices for the proposed wish and an escort authorised to administer such medicines and maintain any devices (via Ambulanz Wonsch or Care Institution). We can carry medications securely for the duration of the wish.

Ambulanz Wonsch has the right to abort the wish and return the patient to the original address at any moment during the execution of the wish.

By completing and returning this application form you accept the above conditions. For further information on the terms used, please discuss with your Palliative Care Providers.

Fill the form

About the wish

Wish date

Wish time

About the patient

Gender
Mr.Mrs.

First name

Last name

Date of birth

Address

Phone number

E-mail

Regarding the Ambulance Wish User (Patient) - Situation and Transportation

Wish User's Weight

Medical Situation and Life Expectancy

Any Medical Devices? Any medicines?

Is there a DNR-CPR in Place?
YesNo

How mobile is the Wish User?
Walking with AssistanceSitting in WheelchairBedriddenOther

About treating Physician

First name

Last name

Phone number

Address

Pick Up Address

Is address same as Patient?
YesNo

Address (if not the same as Patient's Address)

Phone number

E-mail

Level access
Ground FloorFirst FloorSecond FloorThird FloorHigher Floor

Is there a lift available
YesNoN/A

Does the pick-up address have access suitable for a specialized?
YesNo

(Only specialized volunteers can lift users down stairs. It is important to let us know in advance if there are ANY stairs at the property or any other logistic issues at this address.)

Destination Address

Full address

Level access
Ground FloorFirst FloorSecond FloorThird FloorHigher Floor

Is there a lift available at the destination adress?
YesNoN/A

Does the pick-up address have access suitable for a specialized?
YesNo

(Only specialized volunteers can lift users down stairs. It is important to let us know in advance if there are ANY stairs at the property or any other logistic issues at this address.)

Other

Is it possible to fulfil this Wish with a passenger or wheelchair taxi?
YesNo

Any other information to add?

About the Person Referring the Patient

First name

Last name

Address

E-mail

Phone number

Additional information

Any additional information

Preffered language
LuxembourgishFrenchGermanPortugueseEnglish

Carrying out the wish is entirely at your own risk. Do you understand that as a wish applicant?
YesNo

Have you discussed this with the patient?
YesNo

The volunteers and the board of Ambulanz Wonsch are not liable for any unexpected circumstances in any form whatsoever.
Yes

How did you find us?

Have you made a Wish request elsewhere before?
YesNo

Do you give your consent for the Ambulanz Wonsch ASBL to take photographs that we may use on our website to share stories and further promote the charity?
YesNo