IFT Request Form

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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.

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103 Sheppard Drive, Durango CO 81303

Telephone (970) 382-6000

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Website Accessibility Statement

Durango Fire & Rescue (the "District") is committed to ensuring that its services are accessible to all members of the public. As part of this commitment, the District strives to provide an accessible website compatible with the Web Content Accessibility Guidelines (WCAG) version 2.1, AA, and commercial screen reading software. Features of the website are created to allow individuals with vision and other impairments to understand and use the website to the same degree as someone without disabilities.