Transportation enquiry form

Please complete the below form and our staff will get back to you as soon as possible (This form is not for emergencies. In an emergency call 999)

Thank you for completing the form. Your submission has been accepted. We will be in touch soon.

– Elite Medical Team

Transportation service type:

Booked By:

Contact name

Relationship to patient / Job title

Telephone

Email address

Patient Details:

Patient name

Patient’s age

Patients' weight

Patients' mobility

Section (Secure only)

Patients' medical history and current condition

Date transfer required

Collection address

Destination address

Do you have a doctors discharge letter? (repatriation only)

Yes No

Do you have a 'fit to fly' certificate from the hospital of discharge? (repatriation only)

Yes No

Do you require overnight stops? (land based transfers)

Yes No

Do you have any escorts/family accompanying you on the transfer?

Yes No

Consent to use information

I agree to Elite Medical using this information to arrange transport, as described in our privacy policy

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