IFT Form

Patient Information

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

Transport

From
To
Country*
Country*
Facility*
Facility*
Province*
Province*
Town
Town
Address
Address
Contact no.
Contact no.
Complex
Complex
Floor/Room/Ward
Floor/Room/Ward
Closest Landmark
Closest Landmark
Referring Doctor
Receiving Doctor
Pickup Date*
Appointment Date*
Pickup Time*
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
DiagnosisDate of Admission
Is the patient in isolationReason for patient isolation
Number of Infusion PumpsReason for Transfer
Additional infomation for transfer
Reason for transfer /Remarks
*Fields are mandatory