Inter Facility Transport Form
Fill this form out anytime the hospital calls for an Inter Facility Transport
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
What private ambulance or aeromedical companies have been contacted. ETA for each company contacted and ETA (in minutes for each)
Check
Enter ETA Number in Minutes
Shoreline
Personal Care
Care Flight
LifeStar
Meducare
Other
Patient Age
Patient Gender
Please Select
Male
Female
Other
Unknown
Patient Diagnosis
Enter Pick-up Location Information
Enter Info
Unit
Bed
Transferring physician
First and Last Name
Receiving Hospital
Select from Below
Savannah Memorial
Coastal Carolina
MUSC
Augusta
Other
Enter Drop-off Location Information
Enter Info
Unit
Bed
Is the patient's medical record and transfer paperwork complete?
Yes
No
If no, when will patient be ready?
Is the patient active or preterm labor?
Yes
No
Has a specialty ground or air transport team been requested.
Yes
No
Is the patient on medication to stop labor?
Yes
No
Has an OB nurse been assigned to the tranport?
Yes
No
Contact the BC and advise him of this OB information
Is the patient less than 10 years old?
Yes
No
Has a specialty ground or air transport team been requested?
Yes
No
Has a nurse been assigned to the transport?
Yes
No
Is child safety seat available (if patient less than 7 years of age)?
Yes
No
Contact the BC and advise him of all the child information
Is the patient intubated?
Yes
No
Has a nurse or respiratory therapist been assigned to the transport?
Yes
No
Contact the BC and advise him of al the respiratory information
Is the patient on any drips or blood products?
Yes
No
Has a nurse been assigned to the transport?
Yes
No
Contact the BC and advise him of all drips and blood product information
Is special equipment required?
Yes
No
Has a nurse been assigned to the transport?
Yes
No
Contact the BC and advise him of all special equipment information
Enter work email
*
Enter only the first part of your Town before the @
Print
Submit
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