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 isolationNumber of Infusion Pumps
Reason for TransferAdditional infomation for transfer
Confirmed COVID-19*Person under investigation: respiratory condition/ fever/ COVID-19*
Reason for transfer /Remarks
*Fields are mandatory