IFT Form

Patient Information

Your Name:*
Title:
First Name:*
Last Name:*
Gender:*
ID No.:
Age:*
Date of Birth:
Medical Aid:
Medical Aid No.:
Medical Aid Plan:
Contact Number:*

Transport

From
Country*
Facility*
Province*
Town
Address
Contact no.
Complex
Floor/Room/Ward
Closest Landmark
Referring Doctor
Pickup Date*
Pickup Time*
To
Country*
Facility*
Province*
Town
Address
Contact no.
Complex
Floor/Room/Ward
Closest Landmark
Receiving Doctor
Appointment Date*
Appointment Time*

Clinical Data

Ventilation*INTRAVENOUS LINES*
Syringe Drivers*Infusion Pumps*
Incubator*Urinary Catheter*
Oxygen*Blood Pressure Systolic
Blood Pressure DiastolicPulse
SPO2Respiratory Rate
GCSHGT
TempHB
High Risk DiagnosisDiagnosis
Date of AdmissionIs the patient in isolation
Reason for patient isolation*Number of Infusion Pumps*
REASON FOR TRANSFER*Additional infomation for transfer*
Confirmed COVID-19*Person under investigation: respiratory condition/ fever/ COVID-19*
Nursing Unit*
Reason for transfer /Remarks
*Fields are mandatory