Repatriation / Ambulance Transfer Request Form
Salus NE Ltd
Person Booking The Transfer
Forename
*
Surname
*
Company/Organisation
*
Your Role
*
Phone Number
*
Email Address
*
How Did You Hear About Us?
*
Please Select
I'm A Previous Customer
Search Engine (i.e Google)
Online Advertisement
Social Media
Friend / Family Member
Salus NE Employee
Customer Referral
Address
*
Address Line 1
Address Line 2
City
County
Postcode
Are The Billing Details The Same As The Details Listed Above?
*
Yes
No
Billing Details
Forename
Surname
Company/Organisation
*
Phone Number
*
Email Address
*
Address
*
Address Line 1
Address Line 2
City
County
Postcode
Patient Details
Forename
*
Surname
*
Date of Birth
*
Gender
*
Home Address
*
Address Line 1
Address Line 2
City
County
Postcode
GP Surgery
*
NHS Number
*
Patient Histroy
Patients Past Medical History
*
Is The Patient On Any Medication?
*
Does The Patient Have Any Allergies?
*
If Yes, Please List The Allergen
Does The Patient Have Any of The Following In Place?
*
DNAR / DNACPR
EHCP
DoLS
None Of The Above
Other
Reason For Transfer
Reason For Transfer
*
Patient Transport - Outpatient Appointment
Patient Transport - Discharge From Hospital
Patient Transport - Home to Care Facility (i.e Care Home / Nursing Home)
Patient Transport - InterFacilty Transfer
Emergency Transport - Critical Care Transfer (InterFacility)
Emergency Transport - Pallative Care
Repatriation - Transfer From Another Country to UK Hospital
Repatriation - Transfer From Another Country to Care Facility
Repatriation - Transfer From Another Country to Home Address
Repatriation - Transfer From Airport to UK Hospital
Repatriation - Transfer From Airport to Care Facility
Repatriation - Transfer From Airport to Home Address
Other
What Is The Patients Current Condition? Are They Stable For Transport?
*
Journey Details
Pick Up Date
*
Pick Up Time
*
Pick Up Location
*
Address Line 1
Address Line 2
City
County
Postcode
Drop Off Location
*
Address Line 1
Address Line 2
City
County
Postcode
Transfer Category
*
Please Select
Category 1 Transfer
Category 2 Transfer
Category 3 Transfer
Category 4 Transfer
Blue Light Authorised
*
Please Select
Yes - Registered HCP Approved
No
Type of Vehicle Required
*
Please Select
Emergency Ambulance (Blue Light)
Rapid Response Vehicle (Blue Light)
NEPTS Ambulance
Crew Skill Level
*
Rows
1 Required
2 Required
Paramedic
Emergency Medical Technician
Nurse
Emergency Care Assistant
Ambulance Care Assistant
Transfer Requirements
Does The Patient Require Airway Management
*
Yes
No
Is The Patient On A Ventilator?
*
Yes
No
Does The Patient Require Cardiac/Observation Monitoring?
*
Yes
No
Does The Patient Require Medication On Route?
*
Yes
No
Does The Patient Require Oxygen On Route?
*
Yes
No
Oxygen Flow Rate
*
Is There Any Other Requirements Our Crew Need To Be Aware Of?
*
Patient Mobility
Patient Mobility - Select all that apply
*
Walker (W1)
Walker With Assistance (W1A)
Double Crew (DC2)
Wheelchair With Assistance of 1 (WC1)
Wheelchair With Assistance of 2 (WC2)
Electric Wheelchair With Assistance of 1 (EWC1)
Electric Wheelchair With Assistance of 2 (EWC2)
Bariatric Wheelchair With Assistance of 2 (BWC2)
Stretcher (ST2)
Critical Care Stretcher (CST2)
Bariatric Stretcher (BST2)
Multi Crew of 3 (MC3)
Multi Crew of 4+ (MC4+)
Eligibility Questions
Is The Patient Over 18 Years Old?
*
Please Select
Yes
No
If Under 18 Years Old, Will There Be An Escort With The Patient?
*
Please Select
Yes
No
Family or Medical
Is The Patient Detained Under the Mental Health Act?
*
Please Select
Yes
No
Does The Patient Require Skills Above That of A Paramedic?
*
Please Select
Yes
No
If Yes To The Above Question, Is There A Medical Escort Travelling Including A Doctor?
*
Please Select
Yes
No
Does The Medical Escort Need Returning To The Pick Up Location, After The Transfer, By Our Crew?
*
Please Select
Yes
No
Does The Patient Have Any Current IPC Issues or Ongoing Infections?
*
Please Select
Yes
No
Does The Patient Exceed The Weight of 160kg And Have Limitations Due To Their Weight?
*
Please Select
Yes
No
Does The Patient Require Equipment Outside Of Normal Use Ambulance Equipment?
*
Please Select
Yes - No Medical Escort
Yes- Medical Escort To Manage
No
E.g Syringe Drivers, Anaesthetist Equipment
By submitting this form, I understand that I am requesting a quotation for the services of Salus NE Ltd (T/A Salus Medical). I acknowledge that completion of this form does not constitute a firm booking. I have completed this form with the correct information to the best of my knowledge and will undertake to inform Salus NE Ltd of any changes to the information. I have read and will comply with Salus NE Ltd standard terms and conditions. I will forward all relevant documentation to Salus NE Ltd.
*
I Agree
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