SECURE TRANSPORT BOOKING FORM
24hr Booking Line
0345 350 3797
AMBULANCE BOOKING FORM
Average time to complete is 5 minutes
Date of Transport
Name of Hospital/Provider requesting Transport
Collection address including post code *
Name of person making this booking
Email of person making this booking *
Name of person authorising the booking
Email of person authorising this booking *
Position held (of person authorising the booking)
Name of Collection Ward
Destination Hospital (Full Address Including Postcode)
Destination Ward and contact name (where known)
Destination Ward/Hospital Telephone Number
Pick up time
Vehicle Type Required
High Secure with Secure Cell
Mobility - Wheelchair access
Name of patient
Under which section *
If "Other" Please specify which section below
Patient likes to be called (if different from above)
Date of birth
Is the service user aware that they are being transported?
Do you require the use of mechanical restraint (handcuffs)?
If yes, please state the reason why handcuffs are being requested?
Current Risks (Please Mark All)
Sexually inappropriate behaviour
Gender Issues (staffing preference)
Racial Issues (staffing preference)
If not listed above, please specify other known risks including current behaviour (at time of booking) and historical risk. Please also provide information or share information from past experience that could assist us in best managing the above mentioned risk. Also, who is at risk?
Please note additional information based on the above risk (eg. type of sexually inappropriate behaviour or reason for staffing preference)
Is there a known trigger for behaviour? If yes, please state the trigger and how it effects the behaviour.
Are there any illnesses, injuries or disabilities that we should be aware of
If yes to the above, how is this managed
Does the patient have any sensory impairment?
If other, please specify
May RRS Ambulance offer a meal (if conveyance falls over a mealtime or on longer journeys)?
Are there any known allergies or special dietary requirements?
Will the Service User be medicated prior to conveyance?
How many staff do you require RRSAmbulance to provide?
Driver plus one escort (Recommended for Non-Secure (Low Risk) and Informal Patients)
Driver plus two escorts (Recommended for medium Risk Patients)
Driver plus three escorts (Recommended for High Risk Patients)
Additional requirements or information
Number of hospital staff accompanying the Patient
Have they been trained in Physical Control in Care (Restraint trained)?