Book Patient Transport

Thank you, your request has been sent. Our team will call you to confirm the booking, crew and price. If you have not heard from us within one working day, please call 01823 214134.

This is not an emergency service. If someone is seriously ill or injured, call 999. For journeys within the next 24 hours, please phone us on 01823 214134 as well as sending this form.

Tell us about the patient and the journey and we will come back to you to confirm availability, the right crew and vehicle, and a price. Sending this form is a request, not a confirmed booking. Fields marked * are required.

1. Your details

Your full name *

Relationship to the patient *

Phone number *

Email address *

Organisation, ward or department (if booking on behalf of one)

Who is paying for the journey? *

Purchase order or claim reference

2. Patient details

Patient's full name *

Date of birth *

Sex

NHS number (if known)

Approximate weight (kg) *

Approximate height (cm)

Patient's phone number

Language or communication needs

Next of kin name

Next of kin phone

Weight helps us send the right stretcher, carry chair and crew size. An estimate is fine.

3. Mobility and medical needs

How does the patient travel? *

Can the patient move from bed or chair by themselves? *

Yes With help of one person No, needs full assistance or a hoist

Reason for the journey and main medical condition *

Does the patient need oxygen? *

No Yes

Oxygen flow rate (litres/min) and device

Any known infection risk? *

None known Yes

For example MRSA, C. difficile, COVID-19, flu, norovirus or diarrhoea and vomiting in the last 48 hours.

Infection details

DNACPR or ReSPECT form in place? *

Confusion, dementia, learning disability or mental health needs?

Allergies

Equipment travelling with the patient

Anything else the crew should know?

4. Collection

Collection date *

Collection time *

Collecting from *

Ward, department or room

Collection address *

Postcode *

Contact name and phone at collection

Access at collection

5. Destination

Going to *

Appointment or arrival time needed

Ward, department or clinic

Destination address *

Postcode *

Access at destination

6. Return journey and escorts

Do you need a return journey? *

No, one way Yes

Return date

Return time

Number of escorts travelling

Escort name(s)

Luggage or belongings

Any other information

7. Consent The information I have given is accurate to the best of my knowledge. * I have the patient's permission (or am acting in their best interests) to share their health information with Apex Medical & Rescue so that it can plan and provide this journey. See our privacy policy. * I understand this is a booking request and the journey is not confirmed until Apex contacts me. *

Book Patient Transport

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