IFT REQUEST

Home IFT Request

Inter-Facility Transfer Request

Please Complete the Form Below

First Name

Last Name

Contact Number

First Name

Last Name

Age

Date of Birth

ID Number

Billing Type

Medical Aid Name

Medical Aid Number

Medical Aid Plan / Option

Facility Name

Facility Collection Address

Ward Name

Bed Number

Referring Out Doctor

Collection Date

Requested Collection Time

Destination Facility Name

Destination Address

Destination Ward Name

Destination Bed number

Diagnosis

Admission Date

Heart Rate

Blood Pressure

Respiration Rate

Oxygen Saturation

GCS

Temperature

HGT

Covid Status

Last Covid Test Date

Attachments

Is the patient isolated?

Reason for Transfer

Any other general information required for transport