IFT Request Form Today's Date (required) Proposed Transport Date (required) Proposed Transport Time (required) Requested by: (required) Contact Phone (required) PATIENT PERSONAL INFORMATION Full Name (required) Age (required) DOB (required) REFERRING HOSPITAL INFORMATION Name of Hospital (required) Name of Physician (required) Unit/Room# (required) RECEIVING HOSPITAL INFORMATION Name of Hospital (required) Hospital Address (required) Hospital Contact Phone (required) Name of Physician (required) PATIENT CARE INFORMATION Patient Insurance Company (required) Insurance ID# (required) Reason for Transfer (required) Current Diagnosis/Brief History (required) Current Medications (required) ALS Special Needs Intravenous Access (required) Yes No Has patient exhibited verbal or physical violence toward staff? (required) Yes No Has chemical/physical restraint been used for the patient? (required) Yes No Ambulatory (required) Yes No Family member with patient? (required) Yes No Is there a current mental health hold in place? (required) Yes No If you answered "YES" to the mental health hold, please give the date and time. There was a problem saving your submission. Please try again later. Please wait while your submission is being saved... Submitting...Submit Thank you, your submission has been received.
