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ONLINE PATIENT TRANSFER REQUEST

CONTACT PERSON FIRST NAME *

CONTACT PERSON Last Name *

Email *

Phone *

Pick Up Now ASAP
Yes No

Options
One Way Call Return Nurse Return Wait & Return

Pick Up Date

Pick Up Time

APPOINTMENT TIME

ESTIMATED WAIT TIME

Mode of Transport

# OF PASSENGERS

PICK UP LOCATION

(IF PRIVATE RESIDENCE) STAIRS
Yes No

NUMBER OF STAIRS

(IF WHEEL CHAIR) DOES THE PATIENT HAVE THIER OWN WHEEL CHAIR.
Yes No

WHEEL CHAIR WIDTH

DROP OFF LOCATION

PATIENT REFERENCE INFO

Patient First Name

Patient Last Name

Weight

Unit

PRECAUTIONS

Department Billing Unit

Patient ID

PO (IF Required)

Oxygen Required
Yes No

LPM

DOB

Escort (RN. PSW, Family, Other)

DNR
Yes No

Payment Type

Notes

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CTG Medical team upholds rigorous standards of excellence within the organization and across the broader healthcare community. We strive to provide the best care possible and create an environment where everyone feels valued and respected.

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1357 Niagara Stone Rd,
Niagara-on-the-Lake,
ON L0S 1J0, Canada

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