make an online booking National Patient Transport

Service when you want it!

*Please note: this form is for use by customers with an existing account. If you are a new customer, require a High Acuity Transport Service or your patient is paying by cash or credit card please call 1300 628 728 to make a booking..

PATIENT & TRANSPORT DETAILS
^ Patient First Name:
^ Patient Last Name:
^ Patient DOB:
^ UR Number:
^ Date Required:
^ Pick-up Time:
^ Appointment Time:
Return Required:	PLEASE SELECT>> Not required Return Wait & return (fees apply)
Category Required:	PLEASE SELECT>> Required within 90 minutes Required within 120 minutes Non-critical within the next 4 hours Booked 24 hours in advance *Country or Regional Transfers * = 24 hrs notice required for this category NB. For emergencies call '000'
Pick-up Location (ie hospital):
Pick-up Point (ie ward):
Destination (ie hospital):
Drop-off Point (eg radiology):
Service Required:	PLEASE SELECT>> NPT MAS RAV NB. If your Service Required is not listed, please contact Bookings on 1300 628 728
Transport Type:	PLEASE SELECT>> Stretcher Walker Hoist PODS NB. If your transport type is not listed, please contact Bookings on 1300 628 728
^ Diagnosis:
Weight (kg):	NB.If over 155kg please contact bookings on 1300 628 728
Clinical Requirements:	Nil Monitor IV O2 GTN	Heparin Voluntary Patient Involuntary Patient NFR
	Other (please specify):
Acuity Level:	High Acuity NB.Requires phone booking please call 1300 628 728 Medium Acuity IV Crystalloid, O2, GTN, Heparin, Cardiac Monitoring and Psychiatric Transfers (Voluntary or Involuntary) Low Acuity No Clinical Requirements, Chronic Oxygen Dependency.
Infectious:	Yes, please indicate type: No
Escort:	Yes PLEASE SELECT>> Family Medical No
^ Authorizing Doctor:
Additional Comments:
Billing information:	PLEASE SELECT>> *Ambulance Subscriber *DVA *Pension *Private Health Insurance *TAC *Work Cover Hospital Liability * = reference number required
Claim or Reference number: (ie Pension, DVA etc)
If billed to Private Health Insurance, please specify fund
Cost centre (if applicable):
YOUR DETAILS
^ Your Name:
Telephone:
Fax:
^ Email:
Name of Desk Clerk or Nurse in charge:
Confirmation required	Yes No
^ indicates required field