Transportation form

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– Elite Medical Team

Transportation service

Booked By:

Contact name

Relationship to patient / Job title

Telephone

Email address

Approved by (if applicable)

Trust (if applicable)

PO number

Budget code

Patient Details:

Patient name

Patients' age

Patients' weight

Patients' mobility

Section

Consent

Patients' medical history and current condition

Date transfer required

Collection address and contact number

Destination address and contact number

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

Amount of baggage

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