SECURE AMBULANCE BOOKING FORM
All the data entered on this form will be encrypted and send to a secure server. The forms are GDPR compliant
Name of person making this booking
*
First Name
Last Name
Email of person making this booking
*
example@example.com
Name of Person Authorising this booking
*
First Name
Last Name
Position held (of person authorising this booking)
Email of person authorisation this booking
example@example.com
Date Transport is required
*
/
Day
/
Month
Year
Date
Time Transport is required
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name & Address of Collection Point
*
Street Address
Street Address Line 2
Town
County
Post code
Phone Number of collection Facility
-
Area Code
Phone Number
Date of collection
*
/
Day
/
Month
Year
Date
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Name & Address of Drop off Point
*
Street Address
Street Address Line 2
Town
County
Post code
Phone Number of Drop off Facility
*
-
Area Code
Phone Number
Patient Current Risks and Severity
*
Physical Agression
Verbal Aggression
Physical Aggression
Sexually inappropriate behaviour
Self harm
Gender Issues (staffing preference)
Racial Issues (staffing preference)
Patient Current Risks And Severity
Absconsion Risk
Physical Aggression
Verbal Aggression
Sexually inappropriate behaviour
Self harm
Gender Issues (staffing preference)
Racial Issues (staffing preference)
Other
Absconsion Risk
Low
Medium
High
Physical Aggression
Low
Medium
High
Verbal Aggression
Low
Medium
High
Sexually Inaapropriate Behaviour
Low
Medium
High
Verbal Aggression
Low
Medium
High
Self harm
Low
Medium
High
Gender issues (Staffing preference)
Low
Medium
High
Racial Issues (Staffing preference)
Low
Medium
High
If not listed above, please specify other known risks including current behaviour (at time of booking) and historical risk. Please also provide information or share information from past experience that could assist us in best managing the above mentioned risk. Also, who is at risk?
Is there a known trigger for behaviour? If yes, please state the trigger and how it effects the behaviour.
If yes to the above, how is this managed
Does the patient have any sensory impairment?
Sight
Hearing
Intoxication
Other
May RRS Ambulance offer a meal (if conveyance falls over a mealtime or on longer journeys)?
*
Yes
No
Are there any known allergies or special dietary requirements?
*
Yes
No
Unknown
Will the Service User be medicated prior to conveyance?
*
Yes
No
How many staff do you require RRSAmbulance to provide?
*
Driver Only Driver plus two escorts (Recommended for medium Risk Patients)
Driver plus one escort (Recommended for Non-Secure (Low Risk) and Informal Patients)
Driver plus two escorts (Recommended for medium Risk Patients)
Driver plus three escorts (Recommended for High Risk Patients)
Additional requirements or information
Number of hospital staff accompanying the Patient
*
None
One
Two
Three
Have they been trained in Physical Control in Care (Restraint trained)?
*
Yes
No
Should be Empty: