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Travel Information Form

Request for Service Date: *
Request By: *
Position:

Sending Facility Information
Sending Facility: *
Department:
City: *
Country: *
Phone: *
Fax:
Sending Physician:
Physician Phone:

Receiving Facility Information
Receiving Facility:
Department:
City: *
Country: *
Phone:
Fax:
Receiving Physician:
Physician Phone:

Request Date of Travel:
Alternate Date:
Family Member to Travel: *
Patient/Family Citizenship: *

Medical Information Form

This form is intended to provide CONFIDENTIAL information to enable our Call Centre Staff to assess the needs of the patient during travel to ensure the patient's complete medical needs are met while in transit.

Patient's Name: *
Sex: *	MaleFemale
Date of Birth: *
Primary Diagnosis: *
Date of Diagnosis: *
Secondary Diagnosis:
Current and Past Medical History: *
Passenger's Weight: *
Current Medications: *
Describe Current Level of Physical Activity: *
Special Needs, Care or Additional Information: *

Contagious/Communicable Disease or Infections: *	YesNo
If Yes please specify:

Is the patient currently receiving oxygen: Continuous: PRN:	YesNo
If Yes please specify flow rate:

Additional comments or information:

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