Quote for Patient Transfer/Repatriation
Name of person booking
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Name of patient
First Name
Last Name
Date of Birth of patient
Address to pick patient up from
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is access like to pick up? ie is the patient upstairs/downstairs? How easy is it to access with a wheelchair or stretch if required?
Address to take patient to
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What is access like to drop off? ie is the patient upstairs/downstairs? How easy is it to access with a wheelchair or stretch if required?
Date of transfer (if unsure put a possible date and comment underneath)
-
Month
-
Day
Year
Date
Any other possible dates
Time
Hour Minutes
AM
PM
AM/PM Option
How mobile is the patient?
Fully mobile
Able to walk short distances with walking aids
Able to sit in a wheelchair if helped into
Fully bedbound
What further needs or medical requirements does the patient have?
Will anyone be travelling with the patient: if so who? (If an air ambulance medical team will they need returning to airport?)
Email for invoicing
example@example.com
Any further information
Have you read and do you agree to our terms and conditions (link on bottom of website KingsMedicalServices.com)
Yes
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