Non Emergency Stretcher & Clinic Transport Services Renal Patient Booking Form
For Quarter Ending: March 
September  December
June
Stretcher Transport Fax: 1300 366 314
Stretcher Phone: 1300 366 313
Clinic Transport Fax: 1300 361 929
Dialysis Days: Mon 
Wed 
Fri 
Recurring Booking: Yes
Tues 
Thur 
Sat  Sun 
Commencement Date:
Contact Name:
Contact Fax Number:
Appointment Time:
Usually Dialyses For:
Return Trip required: Yes
No
Clinic Transport Phone: 1300 360 929
No
End Date:
Hours
If yes please estimate time:
Suitable for Multi Load: Yes
Patient Details:
No
Gender:
Surname:
Male 
Given Name:
Pick-up Location: (include full address and telephone number)
Current Diagnosis:
Female
Age:
DOB:
Receiving Dialysis Unit: (include full address and telephone number)
Infectious: Yes No
Medical History:
If yes specify:
Acuity/Mobility:
*Refer NEPT Regulations

Stretcher Low Acuity**

Stretcher Medium Acuity

Stretcher High Acuity*



Wheelchair Confined
Walker Assist (Wheelchair assist to/from vehicle)
Walker (Can ambulate and climb 3 steps with assistance)
Escort: Medical
Family*
Special Requirements:
Patient Weight:
Equipment/Mobility Aids:
(specify)






Cardiac Monitor
O2 – Litres/minute:
I/V Insitu - Contents


Other:
Responsible Party:
< 160kg
160- 230 kg
230 kg +
Heparin
G.T.N
Please specify one of the following:
Specify Number: ____________
 Pension
 DVA
 ASV Membership
 Hospital
* Subject to vehicle capacity
Number: ________________________________________
Name of Authorising Nephrologist:
Authorising Dialysis Hub/Satellite:
Signature:
Contact Name and Number (booking agent):
*Please note that by using this booking form you acknowledge that the patient has a bona fide medical reason for requiring transport by Ambulance Victoria Non-Emergency Patient Transport.
The information contained in this facsimile message may be confidential, and may also be subject of intellectual property. If you are not the intended recipient, any use, disclosure or copying of this document is unauthorised. If you have received this document in error, please phone 1300 360 929