Section 1: Contact & Billing Information (The Booker)

Booking Entity *

• Private Individual
• Private Facility / Organisation
• NHS Trust / Organisation
• Other

Booker Name *

Booker Phone *

Booker Email *

Reason for Transfer * Select reason Discharge Inter-hospital transfer Appointment Other

Billing PO Number (if applicable)

Section 2: Patient Details

Full Patient Name *

Date of Birth *

NHS Number (if applicable)

Known Allergies (if any)

Does a family member/clinician need to escort the patient? *

Yes No

Section 3: Transfer Logistics

Pick-up Details

Pickup Location Name *

Full Address *

Required Pick-up Date *

Required Pick-up Time *

Access Issues (Stairs, Lift, etc)

Drop-off Details

Dropoff Location Name *

Full Address *

Required Drop-off Date *

Required Drop-off Time *

Access Issues (Stairs, Lift, etc)

Estimated Waiting Time (hours)

Include any expected on-scene time for crews.

Section 4: Clinical & Mobility Assessment (Crucial for Allocation)

A. Mobility

Primary Mobility Status (Select One) *

• Ambulant (Walks independently)
• Walking with assistance (Cane/Frame)
• Wheelchair Dependent
• Stretcher / Ambulance Cot Required

Approximate Patient Weight (Needed for Manual Handling) *

B. Clinical Status

Is the patient Medically Stable and Fit for Transfer? *

Yes No (Please provide details below)

Does the patient require any of the following during transfer?

Continuous Oxygen Therapy

Continuous Clinical Monitoring / Obs

IV Infusion / Pump

Other ongoing medical requirements

Known or Suspected Infection Control Risk? Yes

C. Behavioural / Mental Health Assessment

Is the patient detained under the Mental Health Act? *

Yes No

Is there a known risk of challenging or violent behaviour? Yes

Section 5: Final Notes & Submission

Any additional notes for the crew or scheduler

Special Requirements

Submit Mental Health Transport Request