Booking Form

Your Name *

Your Email *

Your Phone *

REFERRING HOSPTIAL (referring hospital accepts responsibility for payment and transfer by air of the patient named below)

Referring Hospital *

Authorising Doctor *

Ward *

Phone *

Transfer Date Required *

Ward Contact *

Collection or Delivery? *
—Please choose an option—Patient to be collected by GroundmedPatient to be delivered by Hospital

Transferred by: *
—Please choose an option—AirGround

RECEIVING HOSPTIAL

Receiving Hospital *

Receiving Ward *

ACC Doctor *

Bed Confirmed *
—Please choose an option—YesNo

Delivery or Collection? *
—Please choose an option—Patient to be delivered by GroundmedPatient to be collected by Hospital

PATIENT DETAILS

Patient Name *

Patient Date of Birth *

Patient Gender *
—Please choose an option—MaleFemale

Patient Weight (kg) *

Infectious *
—Please choose an option—YesNo

DrainsNasogastricCentral lineIDCWounds

O²MonitorIV infusionSuctionStretcherWheelchairWalk Assist

Name of Relative *

Relative's Weight (kg) *

Medical Conditions / Other Details