Quinte Patient Transfer Service. A comfort, secure patient transfer service you can trust

QPTS MEDICAL TRANSFER SERVICE REQUEST FORM

Patient Name:(required)
E-Mail:(required)
Pick up Date:(required)
Pick up Time:(required)
Appointment Time
Appointment with
Pick up Location:Floor Room Number
Pick up City
Other(not listed)
Drop off location: Facility/Address
Drop off City
Other(not listed)
Special Instructions

OneWay
Transfer with Return @ ;(indicate approximate return time)
Wait & Return (crew will stay with Pt and provide care)

Please check the appropriate boxes
Pt is receiving O2 Number of L
Pt requires contact precautions
Pt has a completed DNR form
Pthas an IV Pt has a cognitive impairment
Pt weight exceeds 250 lbs
Someone will travel with Pt
Stairs at sending/receiving address
Pt will be traveling by stretcher
Pt will be traveling by wheelchair
Pt will be traveling by wheelchair and does not require any medical care

7am - 7pm Mon- Fri
Weekends and Ontario Civic holidays must be pre-booked 24 hrs in advance on the last business day.

All other times are recommended to be pre-booked to meet your needs. PLEASE CALL ANYTIME FOR A QUOTE

Quinte Patient Transfer Service
PO Box 1255, K8V 5R9
Trenton, Ontario

	Phone: (613) 968-1945 Email: info@qpts.ca