Ambulance Transport Enquiry Form

Ambulance Transport Enquiry Form

For use with Private Ambulance Transport and Repatriation Enquiries
About You

Details of the person making the request
Name *

First Name Last Name
Email *
example@example.com
Phone Number *

Area Code Phone Number
Relationship to Service User *
Who's Travelling?

Details of the Individual Requiring Transport.
Name *

First Name Last Name
Date of Birth *

Month Day Year
Date of Birth
Gender (Identified)

Male Female
Estimated Weight (Kg/Stones) *
Please confirm whether the value is Kg or St.
Service User Preferred Contact Method *

Email Telephone Please do not contact the service user directly
Service User Contact Email (If Appropriate)
example@example.com
Service User Contact Tel (If Appropriate)

Area Code Phone Number
Is the Service User currently suffering from any of the conditions below? *

None MRSA C-Diff Norovirus Hepatitus
Covid-19 Status

It is important to establish each patient's COVID-19 status before confirming a booking. If it is essential that the patient is accompanied by a parent, carer or comforter, then that person should also be screened at this point. the symptoms listed in the latest NHS case definition of COVID-19 are: (1) A New Continuous Cough (A new, continuous cough means coughing for longer than 1 hour or 3 or more coughing episodes in 24hrs. If the patient usually has a cough, it may be worse than normal. (2) New Fever (High Temperature), (3) New loss of, or change in, sense of smell or taste (anosmia). Please note that during this period, all ambulance crews will be taking extra time and precautions. Having COVID-19 Symptoms does not automatically exclude an individual from transport, but may change how the transport is carried out, to ensure best practice.

Type a question *

Yes

Has the service user tested positive for COVID-19 in the last 7 days?

Is the service user waiting for a COVID-19 test, or the results?

Does the service user have a new continuous cough?

Does the service user have a high temperature or fever?

Does the service user have a loss of, or change in sense of smell or taste?

Does the service user live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days? (this includes Care/Nursing Homes)

The Journey

Where are they going?
Journey Date

Day Month Year
Date - If Unknown at this stage, put a rough estimate in the Pickup Notes field below.
Requested Pickup Time

: Hour Minutes AM/PM Option
Pickup Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Pickup Notes
e.g. Ward, Location, Access Details etc.
Destination Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Destination Notes
e.g. Ward, Location, Access Details for Drop Off.
Appointment Time

: Hour Minutes AM/PM Option
Is a Return Journey Required? *

Yes No
Return Journey Date

Day Month Year
Date
Return Journey Pickup Time

: Hour Minutes AM/PM Option
Return Journey Notes
Service User Requirements

How can we safely and appropriately transfer the service user
Transport Mobility *

Stretcher Wheelchair (Own) Wheelchair (Ambulance) Ambulance/Car Seat
Service User Mobility *

Independently Mobile (Requires No Assistance) Mobilises with Assistance (Uses a Stick/Requires the assistance of 1 crew) Mobilises with Difficulty (Uses a Frame or Chair (Requires assistance of 2 crew) Unable to Mobilise (Bed Bound or Unable to Transfer)
Clinical Notes
Please advise of any information regarding the service users clinical condition, relevant medical history, abilities, disabilites and so on.
Special Dietary Requirements
e.g. Allergies etc.
Will the service user be travelling with an escort? *

No - No escort - Service user will be travelling alone Yes - Family Member Yes - Medical Escort (e.g. Carer) Yes - Assistance Dog
Will the service user be travelling with luggage? *

No Luggage Small Bag (e.g. Handbag) Small Case Large Case
Additional Notes
Please advise of any additional information that would be beneficial in the generation of our quotation and provision of transport.
Payment / Billing Information

Who will be paying for this transport if Primary Ambulance Services are the approved provider.
Organisation Name *
Or *Name* if this is being paid for by a private individual
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Email *
example@example.com
Phone Number *

Area Code Phone Number
Authoriser Name (If Different from Booker)

First Name Last Name
Purchase Order Number / Code if Required
Should be Empty:

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Ambulance Transport Enquiry Form

About You

Who's Travelling?

Covid-19 Status

The Journey

Service User Requirements

Payment / Billing Information