MEMORANDUM OF TRANSFER
Section A (To be filled out at Transferring Hospital)
1. Name of Transferring Hospital:
7. Transferring physician's signature of hospital staff acting under physician's
orders:
Legent Orthopedic + Spine
5330 N. Loop 1604 West
San Antonio, Texas 78249
Phone: (210) 877-8000
Name of Transferring Physician:
Phone Number:
Address:
8. Accepting hospital secured by transferring hospital:
Date:
Time:
9. Transferring hospital administration who contacted the receiving hospital :
2. Patient Information (If known)
Patient's full name:
Address:
Phone Number:
Sex:
M
Title:
Time:
10. Type of vechicle and company used:
F National Origin:
Wheelchair van
Physical Handicap:
Stretcher
Will Call
ETA
3. Next of Kin (if known):
Address:
Equipment needed:
Phone Number:
Personnel needed:
Next of Kin notified?
Yes
Facility transported to:
No
4. Date of Arrival:
Time:
5. Initial contact with receiving hospital administration
Date:
Time:
Name and contact person at receiving hospital:
6. Recieving Physician Secured by Transferring Physician: Date:
Time:
Number for Report:
Room #
Diagnosis:
12. Attachments:
X-rays:
MD Progress Notes:
H & P:
Nurses Progress Notes:
Lab Reports:
Medication Record:
Other:
Name of Receiving Physician:
PHYSICAL CERTIFICATION: Based upon the information available at the time of transfer the medical benefits reasonably expected from the provisions of
appropriate medical treatment at another medical facility outweigh the increased risk of transfer to the patient and, in case of labor, the unborn child.
Summary of Risks and beinfets:
Physician:
Section B (To be filled out at receiving Hospital)
1. Name of Receiving Hospital:
4. Receiving physician assuming responsibility for the patient:
Date:
Time:
Address:
Receiving physician's signature:
Phone:
2. Dateof Arrival:
Printed Name:
Time:
Recieving Hospital Administration Signature:
Address:
Phone Number:
If response to the transfer request was delayed beyond thirty (30) minutes, document the reason(s) for the delay, including any agreed time extension.