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English (UK)
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EZRA HEALTHCARE REQUEST FORM
Thank you for choosing Ezra Healthcare. To book with us, please fill in and submit this Triage form. Please view our Privacy Data Protection Policy at https://www.ezra-healthcare.com/privacy-policy/ By submitting the above details in this form, you agree to us contacting you for the purpose of gathering more information on your query. We may also share necessary data with relevant parties to further address your query/request. We will maintain confidentiality of all personal particulars provided. *NOTE* Medical Transport Request Form is for Non-Emergency patient transport. **FOR URGENT CASES PLEASES CALL DIRECTLY OUR HOTLINE.** Please take note of pick up timing can vary +- 30mins from booking time as and when any exceptional circumstances arise, we will make every effort to fulfill your request.
Patient Name
Gender
MALE
FEMALE
Age
Clinic Appointment Time
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
Appointment
*
Address Details
*
Trips
1way Trip
2way Trip
Other
Ward/Unit/Dept/Clinic
from- to which ward/unit/Dept/Clinic
Pick up after / before office hour
5pm
8pm
8am
Other
Sunday/Public Holiday
YES
Other
Request By
*
Name of person who fill up this form
Contact Number
*
-
Area Code
Phone Number
Patient Vital Sign
Stable
Critically ill
Other
PATIENT NEED
*
STRETCHER
WHEELCHAIR
OXYGEN
STAIRCASE
PSYCHIATRIC
ESCORT
Other
ANY INFECTIOUS DISEASE
COVID 19
Other
Number of Family /Medical Personnel
following patient.
Patient Weight above
90kg
120kg
Any other request
Tell us what you need
BILL TO
*
Patient
Nursing Home
Hospital
PWF
IN PATIENT BILLING
Other
*Additional charges
A cancellation charge of 50% of the price may be imposed if you decide to cancel the service after we have arrived at the pick-up point.
$27 cancellation fees within 24 hours.
A waiting charge of $13 may be imposed after the first 15mins waiting.
AED usage $249
No lift landing additional charge of $20 per flight of stairs
Above 10km trip will be a surcharge of $5 per km
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