Medical Transport Request Form

NEW BOOKING
EZRA HEALTHCARE REQUEST FORM

Thank you for choosing Ezra Healthcare. To book your trip 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.**
Patient Name
Gender

Male Female
Age
Pick Up Date *
Address Details *
Trips

1way Trip 2way Trip
Ward/Unit/Dept
from which department or ward
Pick up after 5pm

5pm 8pm
Sunday/Public Holiday

YES
Request By
Name of person who fill up this form
Contact Number

Area Code Phone Number
Patient Vital Sign

Stable Critically ill
PATIENT NEED

Stretcher Oxygen Psychiatric Escort Staircase Escort (min 3hrs $68)
ANY INFECTIOUS DISEASE

COVID 19
Number of Family /Medical Personnel following patient.
Patient Weight above

90kg 120kg
Estimated Fees base on 10km
BILL TO

Patient Nursing Home Hospital
*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 $27 per flight of stairs
- Above 10km trip will be a surcharge of $3 per km
Should be Empty:

EZRA HEALTHCARE REQUEST FORM