Aeromedical Transfer Booking Form
Requesting Client Name
*
E.g. Careflight, Lifeflight
Contact Number
Booking Number/reference
*
PO Number (if required)
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Transfer Details
Date and Time of Pickup
*
-
Day
-
Month
Year
Date
Hour Minutes
Flight/Tail Number
Location of Patient Pickup
Location of Medical Crew Pickup (if different to patient)
Location of Patient Drop Off
Location of Crew Accommodation (if required)
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Patient Details
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date
Gender
Male
Female
Other
Medical History
Allergies
Current Treatments
Provisional Diagnosis
Medications
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Transport Requirements
Vehicle/s
Standard Ambulance
Light/Sirens Capable Ambulance
Medical Support Vehicle (when companion is present)
Other
Priority of Transport (How do you want your PT transferred to location)
*
P1 - Lights and Sirens Urgent
P2 - Lights and Sirens
P3 - Normal Road
Equipment
Monitor/Defib
Oxygen
Wheelchair
Scoop
Spine Board
Other
Please provide any relevant information or notes that may help/impact this transport including special request
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Companion Details
Medical Support Vehicle Required. Max 2 Companions
Full Name
First Name
Last Name
Relationship to Patient
Full Name
First Name
Last Name
Relationship to Patient
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Medical Team
Accompanying Patient
Name
DR
RN
EN
RP
MEDIC
Prefix
First Name
Last Name
Name
DR
RN
EN
RP
MEDIC
Prefix
First Name
Last Name
Name
DR
RN
EN
RP
MEDIC
Prefix
First Name
Last Name
Contact Number For POC (point of contact)
Name of Requester
*
First Name
Last Name
Please provide an email for booking confirmation
*
Submit
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