Patient Information Sheet: Non-Emergency Medical Transport

Fill out this sheet before the transfer and give a copy to the transport team. Download the PDF or print this page.

Scheduled date of transport		Time (AM/PM)
Patient name (last, first, middle)
Patient / hospital ID number		Room
Date of birth
Home address

Family member or legal guardian contacts

1. Name		Relation		Phone
2. Name		Relation		Phone

Discharging physician		Phone
Receiving hospital / facility
Facility address
Facility phone
Receiving physician		Phone