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Request of Ground Ambulance.
Please request a Ground ambulance for an Air ambulance Flight
Name of Air Ambulance / Insurance provider
*
Your reference number
*
Your Email
Patient Name
*
First
Last
Patient Date of Birth
Gender
Please select
Male
Female
Other
Date of Journey
*
DD
/
MM
/
YYYY
Patient Pick up time please
*
HH
:
MM
AM
PM
AM/PM
Please notify us if there will be any
changes or delays from the original time.
Time Flights arriving UK time please
*
HH
:
MM
AM
PM
AM/PM
Please notify us if there will be any
changes or delays from the original time.
Flight number
*
Terminal arrival
Patients Pick up Location
*
Please Include postal code and contact number
Patient drop of location
*
Please Include postal code and contact number
Do You require a Blue light driver?
*
Yes
No
Patients Mobility
*
Walking may require assistance
Wheelchair Required
Stretcher Required
Paediatric Pedi Mate
Incubator (Client to be Provided)
Baby Pod 2 (Client to be Provided)
Other
Journey type
*
Appointment
Appointment - Wait and return
Transfer to Home address
Non Emergency Transfer
Emergency Transfer
ITU/ HUD Transfer
Other (Please Note below)
Medical information about the Patient
Please choose the condition that best describe the patient.
*
Cardiac
Respiritory
Stroke
Cancer
Transplant
Fracture(s)
Menatal Health
Pregnancy
Paediatric
Neonatal
Multiple organ faliure
Head injury (neuro)
Learning Difficulties
Other
Please give a more detailed description of the patients current condition.
*
Please include any relevant past medical history. If there is no History please write none.
Are the any present risks of infections / infectious diseases
*
Yes (Please list below)
No
Please indicate what are the infection risks (Please include Barrier nursing, Gloves, Aprons and mask to be worn)
Infection Risk notes:
Additional Information
Relative Escort
*
Yes
No
Please note due to limited space only 1 relative can travel in the ambulance depending on medical crew
Medical Team
*
Our Ambulance Crew
Doctor(s)
Anaesthetist
Nurse(s)
Paramedic
Advanced Technician
Flight crew Observer
Other
Please note due to limited space only 3 medical personnel can travel in the ambulance. Please write in the other box if there will be more than one member of staff of the same grade (e.g x2 nurses)
Do you require mains Power for monitors/ Ventilators
Yes
No
Any Other Additional information that maybe useful.
Air Ambulance provider Conatct details
Booked By (Full Name)
*
Contact number with EXT
*
Department (e.g Flight ops)
*
Company Name requesting transport
*
By submitting this form, I understand that I am requesting the services of South Coast Medics. I acknowledge that completion of this form does not constitute a firm booking. I have completed this form with the correct information to the best of my knowledge and will inform South Coast Medics of any changes to the information provided.
I understand once a confirmed booking has been made and the ambulance has been booked for transport the provider maybe subject to a cancellation charge if cancelled with less than 24 hours notice or the ambulance is cancelled on route to the aircraft.
www.southcoastmedics.co.uk
*
I Agree
Invoice Details
Name to address invoice to
First
Last
Contact
Invoice Email
Invoice Address
*
Street Address
City
State / Province / Region
Postal / Zip Code
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Haiti
Honduras
Jamaica
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Netherlands Antilles
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Russia
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Singapore
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United Arab Emirates
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Marshall Islands
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New Zealand
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Papua New Guinea
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Burundi
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Country / Region
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