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Request for Transport

Average time to complete is 5 minutes.

Date of Transport*

Pick up time* (24 hour format eg 17:30)

Commissioner Details

Name of person making this booking

Position/Job Title*

Telephone Number*

Email Address*

Funding Authority*

Cost centre code

I have authority to authorise this booking?*
Yes I have authority to authorise

Patient Details

Name of Patient*

Patient likes to be called (if different from above)

Date of Birth

Age

NHS Number*

Gender of Patient*
—Please choose an option—MaleFemale

Under which section*
Section 2Section 3Section 4136InformalOther

If other please specify

Do you require the use of mechanical restraint (handcuffs)?
—Please choose an option—YesNo

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

Current Risk
Absconsion RiskPhysical AggressionVerbal AggressionSexually inappropriate behaviourSelf harmGender Issues (staffing preference)Racial Issues (staffing preference)‘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, 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). 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?
—Please choose an option—YesNoUnknown

If yes to the above, how is this managed?

Does the patient have any blood borne disease?
NoneHIVTBHep BHep COtherIf other, please note in the additional requirements at the bottom of this page

Does the patient have any sensory impairment?
NoneSightHearingIntoxicationOther

Is there a Safeguarding plan or are there any Safeguarding issues for this patient at the moment?
—Please choose an option—YesNo
If Yes, Prometheus Safe and Secure team to ensure this is included in the handover on collection at the hospital

May Prometheus Safe and Secure offer a meal (if conveyance falls over a mealtime or on longer journeys)?
—Please choose an option—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?
—Please choose an option—YesNoUnknown
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.

If yes to the above, how is this managed?

Will the patient be medicated prior to conveyance?
—Please choose an option—YesNo
Please note that we are unable to transport any patient who has been fully sedated

Transfer Details

Details of collection of Patient

(Pick up point)

Collection Ward*

Collection Hospital and Contact name at collection hospital

Collection Postcode (if known)

Details of Destination

The location the patient needs to be transferred to

Destination Ward (where applicable)*

Transport to and contact name if applicable

Destination Postcode

Select which transport service you need
—Please choose an option—Drop off onlyDrop off patient and return staffWait and return

Additional requirements or information

If you do not receive confirmation from the Prometheus Safe and Secure booking office within 15 minutes of completing this form, please contact us on 0800 009 6668 to confirm receipt.

I declare that all the information given is accurate to the best of my knowledge.