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.**
Pick Up Date
from which department or ward
Pick up after 5pm
Name of person who fill up this form
Patient Vital Sign
Escort (min 3hrs $68)
ANY INFECTIOUS DISEASE
Number of Family /Medical Personnel
Patient Weight above
Estimated Fees base on 10km
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: