Medical Transport Request Form

NEW BOOKING
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

MALEFEMALE
Age
Appointment*
Address Details*
Trips

1way Trip2way Trip
Ward/Unit/Dept/Clinic
from- to which ward/unit/Dept/Clinic
Clinic Appointment Time

:HourMinutesAM/PM Option
Pick up after / before office hour

5pm8pm8am
Sunday/Public Holiday

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

Area CodePhone Number
Patient Vital Sign

StableCritically ill
PATIENT NEED*

STRETCHERWHEELCHAIROXYGENSTAIRCASEPSYCHIATRICESCORT min 3hrs
ANY INFECTIOUS DISEASE

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

90kg120kg
Estimated Fees base on 10km
Any other request
Tell us what you need
BILL TO*

PatientNursing HomeHospital
*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
Should be Empty: