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Urgent Care
High-Dependency
Bariatric
Repatriations
VIP
Service Quotation Request
1. Patient
2. Journey & Address
3. Onward Journey
4. Health & Transport
5. Contact & Invoice
Step 1 of 5
1. Patient Information
First Name
Please enter the patient’s first name.
Surname
Please enter the patient’s surname.
Pronouns
He/Him
She/Her
They/Them
Other
Please select or specify pronouns.
Gender
Male
Female
Other
Please select or specify gender.
Weight (kg)
Call us if weight exceeds 115 kg.
Enter a valid weight.
Date of Birth
Please enter the patient’s date of birth.
Age
Additional Needs
Can the service user speak English?
Yes
No
Please indicate English proficiency.
Preferred Language
Please specify preferred language.
Forms held by patient
None
DNACPR (Red Form)
RESPECT (Purple Form)
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2. Journey & Address
Date of Transfer
Not Sure Yet
Please enter the date of transfer or mark “Not Sure Yet.”
Pick-up Time
Not Sure Yet
Please enter pick-up time or mark “Not Sure Yet.”
Journey Type
One-way
Return
Wait & Return
Please select a journey type.
Return Journey Date
Return Journey Time
Estimated Time at Appointment
Appointment Time (if known)
Collection Address
Street Address 1
Enter collection address line 1.
Street Address 2 (optional)
Town/City
Enter town/city.
Postcode
Enter postcode.
Access Requirements (Collection)
Describe access requirements.
Destination Address
Street Address 1
Enter address line 1.
Street Address 2 (optional)
Town/City
Enter town/city.
Postcode
Enter postcode.
Access Requirements (Destination)
Describe access requirements.
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3. Onward Journey
Onward Journey Required?
Yes
No
Please indicate if onward journey is required.
Onward Address
Approximate Wait Time
30 Minutes
1 Hour
1 h 30 m
2 Hours
2 h 30 m
3 Hours
3 h 30 m
4 Hours
4 h 30 m
5 Hours
5 h 30 m
6 Hours
6 h 30 m
7 Hours
7 h 30 m
8 Hours
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4. Health & Transport Specifics
Medical History & Conditions (including mental health)
Provide medical history and conditions.
Does the service user currently have any infectious conditions, such as Covid-19, Norovirus, MRSA or C-DIFF?
Covid-19
Norovirus
MRSA
C-difficile
Other
What medications is the service user currently prescribed?
(Please note any that need taking during transport.)
Is carry chair required to move up or down stairs?
Yes
No
Please indicate whether a carry chair is required.
Total number of steps to carry over
Service User Mobility
Mobilises Independently
Mobilises with Assistance (e.g. walks with stick)
Mobilises with Difficulty (e.g. walking frame)
Unable to Mobilise (e.g. bed bound)
Crew / Vehicle Type Required
Ambulance Car (Single Crew – Driver)
For walking patients only.
Double Crew Non-Emergency Ambulance
Double Crew High-Dependency Ambulance
Double Crew Emergency / Intensive Care Ambulance
Unsure (Please Advise)
Other
Select or specify vehicle type.
Preferred Travel Method
Car / Chair Seating
Travel in Own Wheelchair (Manual & Crash Tested)
Travel in Own Wheelchair (Electric & Crash Tested)
Travel in Own Wheelchair (Specialist & Crash Tested)
Travel on Ambulance Stretcher
Travel in Ambulance Wheelchair
Other
Select or specify travel method.
Will the service user be travelling with an Escort?
No – Travelling Alone
Yes – Family Member
Yes – Carer
Other
Indicate escort or specify other.
Escort Name
Escort Phone Number
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5. Contact & Invoice Details
Applicant Contact
Name
Please enter your name.
Email Address
Please enter your email.
Contact Phone Number
Invoice Payee Details
Organisation Name (if applicable)
Payee Name
Please enter the payee name.
Payee Email Address
Please enter the payee email address.
Payee Phone Number
Please enter the payee phone number.
Invoice Address Street 1
Enter invoice street line 1.
Invoice Address Street 2 (optional)
Town/City
Enter invoice town/city.
Postcode
Enter invoice postcode.
Purchase Order Number / Cost Code (if applicable)
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