On-Line Booking

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* Indicates required field

Patient Name *

First

Last

Date of Birth *

Date Required *

Pick Up Time *

Appointment Time *

Return Transport Required *

Yes No

Category of Transport Required *

Pick Up Location *

Pick Up Point / Department / Ward No. *

Destination / Facility *

Diagnosis / Condition (include secondary conditions) *

Clinical Requirements *

Nil Monitor Oxygen Therapy / Maintenance Suction IV In situ / Maintenance Cardiac Monitoring GTN NFR / DNR (* provide copy to crew)

Other Transport Requirements *

Nurse Escort Family Member Transport (maximum 2) Luggage Meals / Drinks (incl dietary requirements)

Provide Relevant Details *

If any other Clinical Requirements - please list: *

Patient Weight *

Infectious *

No Yes

If YES, please indicate type ( MRSA +, VRE + ) *

Name of Authorising Medical Practitioner *

Additional Information *

Billing Type *

Hospital Direct Health Partners Allianz CTP (MAC - Motor Accident Commission) WorkCover Patient Direct Other

Health Partners / Medibank Private (Ambulance Extras Cover) Member Number *

Allianz CTP (MAC), WorkCover or Other Number: *

Name of Person Booking Transport *

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