Contact | True Medical Transport

T M T

Facility Name

Floor/Unit

Contact Name

Phone # EXT:

Email address:

Tentative PICK UP
DATE:

TIME: FROM

TIME: To

Patient Information
First name

Last name

AGE:

Sex

Weight lbs

Diagnosis & Precautions(Please include IV's/Drains/Trach tube etc)

Pick up location and area:
Name/Address

FLOOR UNIT

Room #

Bed#

Precautions/Covid :

OXYGEN REQUIRED?

Stair chair required? Can pt sit? # of steps:

DNR? _{(document will be required upon pickup)}

Cardiac Monitor required? _{(Stable or unstable - escort required?)}

ESCORT / FAMILY MEMBER TO ACCOMPANY THE PATIENT