Fields marked with * are required
Your Name *
Your Email *
Your Phone *
Referring Hospital *
Authorising Doctor *
Ward *
Phone *
Transfer Date Required *
Ward Contact *
Collection or Delivery? * ---Patient to be collected by GroundmedPatient to be delivered by Hospital
Transferred by: * ---AirGround
Receiving Hospital *
Receiving Ward *
ACC Doctor *
Bed Confirmed * ---YesNo
Delivery or Collection? * ---Patient to be delivered by GroundmedPatient to be collected by Hospital
Patient Name *
Patient Date of Birth *
Patient Gender * ---MaleFemale
Patient Weight (kg) *
Infectious * ---YesNo
DrainsNasogastricCentral lineIDCWounds
O²MonitorIV infusionSuctionStretcherWheelchairWalk Assist
Name of Relative *
Relative's Weight (kg) *
Medical Conditions / Other Details