Direct Line: 0208 226 6369
Email: [email protected]
NON EMERGENCY PATIENT TRANSPORT REQUEST FORM
Date of travel:
Click on arrow and use calendar
Appointment time:
Enter appointment time
Appointment
location:
Ward or Clinic
Patient Details
Surname:
Enter surname
Forename
Enter first name:
Male
Female
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DOB: Click
arrow and
use calendar.
Hospital No:
Enter hospital no
Destination Address:
Pick Up Address:
Enter pick up address
Moorfields at St George’s Hospital
Blackshaw Road, Tooting, London
SW17 0QT
Postcode: Enter postcode
Tel: Enter telephone number
Provide diagnosed medical conditions and understanding of the patients
restrictions: Enter medical conditions
Patient only ☐
Patient and Escort* ☐
*Medical reasons required*
(Only 1 escort allowed)
Mobility Details (Please tick ONE Mobility Criteria)
Standard Car
The patient is mobile and able to
walk. Patient requires a
wheelchair on arrival (tick box)
Walking Ambulance (C5)
The patient requires ramp
access to enter the vehicle and
will travel in their own chair
Chair/Take own
The patient is able to transfer
from their wheelchair into the
vehicle
Chair/Travel in own (C4)
The patient is required to travel
in their own wheelchair (nontransferable)
Two man crew**(C2)
The patient needs an
ambulance with double
crew.
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PTS Stretcher**
The patient needs to lie
down during travel. Please
specify the current weight of
the patient. Requires a
double crew
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** Further
information
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Is oxygen required on board the vehicle?
If yes, please state the litres required
Does the patient have MRSA or another
infectious disease? Please specify.
Moorfields Eye Hospital NHS Foundation Trust
162 City Road London EC1V 2PD
Tel: 020 7253 3411
Website: http://www.moorfields.nhs.uk/
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Direct Line: 020 8725 1873/0208 226 6369
Email: [email protected]
Assessment Questions
The following questions should be asked to the patient over the phone / in person when they
call / attend GP surgery. (Numbers indicated in brackets relates to scoring)
The score required is 4
3. Senses
1. Fitness

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No shortness of breath or exercise
restrictions (0)
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Limited to 50 to 200 metres walking
(1)
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Limited to 0 to 50 metres walking
(2)
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
All senses (0)
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Deaf/Registered Blind (1)
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Needs carer to action medical
treatment (1)
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4. Mental Function

None (0)
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Learning disability/dementia (2)
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2. Mobility

Walks unaided (0)
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
Needs walking aid (1)
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Travel in wheelchair (2)
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Stretcher (4)
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No general ill health issues (0)
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2 Person Chair (2)
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Chronic ill health (1)
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In Own Chair (2)
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Acute ill health (2)
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Own electric chair (2)
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Leg(s) in full POP cast (2)
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Major surgery in last 6 weeks (2)
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
Condition/Procedure precludes driving
(1)
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5. General Health
Total Score
Person Completing Form:
Enter person completing the
form
Email: Enter email address
Telephone No:
Enter telephone number
Office Use (MEH):
Patient Booked ☐
Already on the System ☐
More Information ☐
Rejected ☐ Date: Click on arrow and use
calendar
The completion of this form does not act as confirmation of a transport booking.
An email confirmation or to request of further information will be sent separately.
Moorfields Eye Hospital NHS Foundation Trust
162 City Road London EC1V 2PD
Tel: 020 7253 3411
Website: http://www.moorfields.nhs.uk/