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AMBULANCE TRANSPORT BOOKING FORM ONLINE
*
Indicates required field
Patient Name
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First
Last
Date of Birth
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Date Required
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Pick Up Time
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Appointment Time
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Return Transport Required
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Yes
No
Category of Transport Required
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Low Acuity Discharge
Low Acuity Transfer for Medical Appointment
Low Acuity Transfer to Another Facility
Medium Acuity
High Acuity (RN Escort)
Airport Pick Up (Adelaide)
Long Range Transfer < 200km
Long Range Transfer > 200km
Pick Up Location
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Ashford Hospital
Flinders Private
Griffiths Rehabilitation
Memorial Hospital
Parkwynd
Calvary College Grove
Calvary Central Districts
Calvary North Adelaide
Calvary Wakefield
Resthaven Leabrook
Resthaven Marion
Resthaven Westborne Pk
Ananda Findon
Ananda Modbury TTP
St Andrews Hospital
Sportsmed
Kensington RCF
Murray Mudge NH
Other
Pick Up Point / Department / Ward No.
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Destination / Facility
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Diagnosis / Condition (include secondary conditions)
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Clinical Requirements
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Nil
Monitor
Oxygen Therapy / Maintenance
Suction
IV In situ / Maintenance
Cardiac Monitoring
GTN
NFR / DNR (* provide copy to crew)
Other Transport Requirements
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Nurse Escort
Family Member Transport (maximum 2)
Luggage
Meals / Drinks (incl dietary requirements)
Provide Relevant Details
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If any other Clinical Requirements - please list:
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Patient Weight
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Below 100kg
Between 100kg > 135kg
Above 135kg
Infectious
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No
Yes
If YES, please indicate type ( MRSA +, VRE + )
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Name of Authorising Medical Practitioner
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Additional Information
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Billing Type
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Hospital Direct
Health Partners
Allianz CTP (MAC - Motor Accident Commission)
WorkCover
Patient Direct
Other
Health Partners / Medibank Private (Ambulance Extras Cover) Member Number
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Allianz CTP (MAC), WorkCover or Other Number:
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Name of Person Booking Transport
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First
Last
Contact Number
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-
PLEASE CONTACT IMS 24 HOURS ON
(08)8162 9998
TO CONFIRM TRANSPORT ONCE FORM SUBMITTED.
SUBMIT FORM NOW