BOOK NOW – EC Secure Transport Limited

Request for Transport

Average time to complete: 5 minutes.

Request for Transport

Date of Transport* *

Commissioner Details

Name of person making this booking *

Position/Job Title* *

Telephone Number* *

Email Address *

Funding Authority* *

Cost centre code

Do you have authority to authorize this booking?* *Yes. I have authority to authorize

Name of Patient* *

Patient likes to be called (if different from above)

Date of Birth

Age

NHS Number* *

Gender of Patient* *MaleFemale

If other please specify

Do you require the use of mechanical restraint (handcuffs)?YESNO

If yes, please state the reason why handcuffs are being requested?

‘Please note that a patient may not be transported in the secure area of the vehicle if there are no known risks unless a ‘Patient Authority Form’ has been signed by the patient’.

If not listed above, 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). Including any known triggers for behaviour and how it effects the behaviour

Are there any illnesses, injuries or disabilities that we should be aware of?YESNOUNKNOWN

If yes to the above, how is this managed?

Is there a Safeguarding plan or are there any Safeguarding issues for this patient at the moment?YESNO

May we offer a meal (if conveyance falls over a mealtime or on longer journeys)?YESNO

Please be advised that the meal cost is payable by the bill payer. If there is an expense limit, please include in the notes at the bottom of this form.

Are there any known allergies or special dietary requirements?YESNOUNKNOWN

If yes to the above, how is this managed?

Will the patient be medicated prior to conveyance?YESNO

Please note that we are unable to transport any patient who has been fully sedated

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