IFT Request FormToday's Date (required)Proposed Transport Date (required)Proposed Transport Time (required)Requested by: (required)Contact Phone (required)PATIENT PERSONAL INFORMATIONFull Name (required)Age (required)DOB (required)REFERRING HOSPITAL INFORMATIONName of Hospital (required)Name of Physician (required)Unit/Room# (required)RECEIVING HOSPITAL INFORMATIONName of Hospital (required)Hospital Address (required)Hospital Contact Phone (required)Name of Physician (required)PATIENT CARE INFORMATIONPatient Insurance Company (required)Insurance ID# (required)Reason for Transfer (required)Current Diagnosis/Brief History (required)Current Medications (required)ALS Special NeedsIntravenous Access (required)YesNoHas patient exhibited verbal or physical violence toward staff? (required)YesNoHas chemical/physical restraint been used for the patient? (required)YesNoAmbulatory (required)YesNoFamily member with patient? (required)YesNoIs there a current mental health hold in place? (required)YesNoIf 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...SubmitThank you, your submission has been received.
