Patient Transport Booking Form

Use this form to request a quotation for Ambulance Transportation / Repatriation Journeys.
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About You...

Details of the person making the request
Where did you hear of Medi 4?(Required)

Payment Information

Who will be paying for this transport (if Medi 4 are the successful provider).
Billing/Payment Address(Required)

Who's Travelling..

Details of the individual who requires transport
Gender(Required)

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Service Users Preferred Contact Method
Service User Mobility
Service User Equipment Required to Travel
Is the service user suffering from any of the conditions below?

Location, Patient’s or escorts COVID-19 status?

It is important to establish each patient’s COVID-19 status before confirming a booking. If it is essential that the patient is accompanied by a parent, carer or comforter, then that person should also be screened at this point.

The symptoms listed in the latest NHS case definition of COVID-19 are:

  • new continuous cough (* A new, continuous cough means coughing for longer than an hour, or three or more coughing episodes in 24 hours. If the patient usually has a cough, it may be worse than usual)
  • new fever/high temperature
  • new loss of, or change in, sense of smell or taste (anosmia).

Please note during this period all ambulance crews will be taking extra time and precautions

Have you tested positive for COVID-19 in the last 7 days?(Required)
Are you waiting for a COVID-19 test or the results?(Required)
Do you have a new continuous cough?(Required)
Do you have a high temperature or fever?(Required)
Loss of, or change in, sense of smell or taste?(Required)
Do you live with someone who has either tested positive for COVID-19 or had symptoms of COVID-19 in the last 14 days?(Required)

Where are they going?...

Details of the journey requirements
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Requested Pickup Time(Required)
:
Pickup Address(Required)
1. Pick up Access/Egress: Is there adequate parking outside or near to the property?
2. Pick up Access/Egress : Is the access route from ambulance to door adequate for wheelchair/stretcher?
3. Pick up Access/Egress : Is the access route from ambulance to door clear of steps, twists and turns?
4. Pick up Access/Egress : Is there ramp access to the building?
5. Pick up Access/Egress : Is there adequate lighting to the property entrance?
6. Pick up Access/Egress : Is the patient on ground floor level?
7. Pick up Access/Egress : Is the access door wide enough for a wheelchair/stretcher?
8. Pick up Access/Egress : If there are pets will they be locked away?
9. Pick up Access/Egress : Does the access door allow instant access?
Destintion Address(Required)
1. Destination Access/Egress : Is there adequate parking outside or near to the property?
2. Destination Access/Egress : Is the access route from ambulance to door adequate for wheelchair/stretcher?
3. Destination Access/Egress : Is the access route from ambulance to door clear of steps, twists and turns?
4. Destination Access/Egress : Is there ramp access to the building?
5. Destination Access/Egress : Is there adequate lighting to the property entrance?
6. Destination Access/Egress : Is the patient on ground floor level?
7. Destination Access/Egress : Is the access door wide enough for a wheelchair/stretcher?
8. Destination Access/Egress : If there are pets will they be locked away?
9. Destination Access/Egress : Does the access door allow instant access?
Appointment Time
:
Is a wait and return journey required?(Required)
Is a Return Journey Required?(Required)
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Return Journey Pickup Time
:

Service User Requirements

How can we safely and appropriately transfer the service user.
Is the service user infectious?(Required)

Will the service user be travelling with an escort?(Required)

Will the service user be travelling with luggage?(Required)

Name