Non Emergency Transport Request Form

Booking Facility

Contact Name

Contact Phone No.

Contact Fax No.

Pick up Day

Pick up Date

Pick Up Time

Appointment Time

Authorising Practititioner

Pick Up Location phone

Pick-Up Location (include full address)

Ward/Dept/Residence

Patient's Given Name

Patient's Surname

Age

Gender

Acuity / Mobility

Stretcher Low Acuity Stretcher Medium Acuity Wheelchair Walker Assist Walker (can ambulate & climb with assistance)

Current Medical Diagnosis

Yes No

Patient For

Admit/Discharge Day Surgery Other (specify)

Responsible Part

Patient Pension/DVA WorkCover/TAC Other

Medicare Number

Special Requirements

Cardiac Monitor O₂ - Litres/min IV Insitu - Contents Heparin G.T.N.

Double Load

Yes No

Escort

Medical Family

Return Trip:

Yes No Est Time

Patient Weight

<120kg 120-159kg 230kg 160-229kg

Does the Patient have a positive COVID-19/RSV infection.

Yes, COVID-19 Yes, RSV No

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