You’re offline. This is a read only version of the page.
Skip to main content
Welcome to Patient Transport Booking Request Form
Toggle navigation
Home
Pages
Pages
Subpage 1
Subpage 2
Contact us
Search
Sign in
Email Validation
Please enter your email address
*
*
*
Please enter the one time passcode shared to your email
*
*
Booking Type
Please select one
*
Please select one
Is this a PIPER booking (AV internal use ONLY)
Please select one
Is this an ARV booking (AV internal use ONLY)
Please select one
None of the above
COVID Infection
Does the patient have a positive COVID-19 infection?
*
Does the patient have a positive COVID-19 infection?
Yes
Does the patient have a positive COVID-19 infection?
No
Is the patient Currently quarantined for potential COVID-19 infection?
*
Is the patient Currently quarantined for potential COVID-19 infection?
Yes
Is the patient Currently quarantined for potential COVID-19 infection?
No
Is the patient a healthcare or aged care worker with a headache, myalgia, stuffy nose, nausea, vomiting or diarrhoea?
*
Is the patient a healthcare or aged care worker with a headache, myalgia, stuffy nose, nausea, vomiting or diarrhoea?
Yes
Is the patient a healthcare or aged care worker with a headache, myalgia, stuffy nose, nausea, vomiting or diarrhoea?
No
Has the patient had close contact in the past 14 days with a COVID 19 confirmed case, or have been in a known cluster location? (i.e. aged care facility)
*
Has the patient had close contact in the past 14 days with a COVID 19 confirmed case, or have been in a known cluster location? (i.e. aged care facility)
Yes
Has the patient had close contact in the past 14 days with a COVID 19 confirmed case, or have been in a known cluster location? (i.e. aged care facility)
No
Contact Person's First name
*
Contact Person's Last name
*
Contact Person's Phone (Include Area code and phone number only)
*
ARVIS Case Number
*
PIPER
Do you need a vehicle and/or driver or just a CAD number?
Do you need a vehicle and/or driver or just a CAD number?
Vehicle and/or Crew
Do you need a vehicle and/or driver or just a CAD number?
CAD number only
Vehicle and/or Crew
Vehicle and/or Crew
Driver Only
Vehicle and/or Crew
Crew and Vehicle
Driver only
ALS
MICA
PTO
ATA
PTO and ATA
Crew and Vehicle
ALS
MICA
PTO
ATA
PTO and ATA
Is the crew required to provide patient care?
Is the crew required to provide patient care?
Yes
Is the crew required to provide patient care?
No
Case uses PIPER owned and operated resources
Presenting Problem (Dx)
What is the patient’s diagnosis/presenting problem?
*
Purpose of Transport (P-TAT)
What is the purpose of transport?
*
Vehicle Number
What is the callsign of the resource undertaking the transport?
*
Timeframe
What timeframe do you require the ambulance to attend?
>=0 & <=15mins
>=16 & <=25mins
>=26mins
ARV
What is the timeframe?
0-15 mins
16-25 mins
26-90 mins
>90 mins
What resources do you require?
Driver Only
Crew and Vehicle
Nil (using own vehicle and driver/crew)
Nil (using contractor vehicle and crew, CAD number only)
Driver only
ALS
MICA
PTO
ATA
PTO and ATA
Crew and Vehicle
ALS
MICA
PTO
ATA
PTO and ATA
Are the crew required to provide clinical care for the patient?
Are the crew required to provide clinical care for the patient?
Yes
Are the crew required to provide clinical care for the patient?
No
Presenting Problem (Dx)
What is the patient’s diagnosis/presenting problem?
*
Vehicle Number
Vehicle Resource Type
ARV OV
ARV MATS
Vehicle Resource Type
NPT HATS
NPT CPAV
RFDS HATS
RFDS CPAV
Contractor - Other
CPAV - Other
Vehicle Call Sign
*
Pick-Up Location
*
Hospital Ward / Facility Name
*
Non Emergency Patient Transport Acknowledgements
I confirm that this booking is NOT for emergency transport and the patient can clinically wait for more than 90 minutes for the transport
I confirm that this booking is NOT for emergency transport and the patient can clinically wait for more than 90 minutes for the transport
Yes
I confirm that this booking is NOT for emergency transport and the patient can clinically wait for more than 90 minutes for the transport
No
I confirm this is NOT for patient being transported with a mental health condition
I confirm this is NOT for patient being transported with a mental health condition
Yes
I confirm this is NOT for patient being transported with a mental health condition
No
Acuity Qualification
Does the patient require active clinical monitoring/care or clinical supervision during transport?
Does the patient require active clinical monitoring/care or clinical supervision during transport?
Yes
Does the patient require active clinical monitoring/care or clinical supervision during transport?
No
Is oxygen required?
Is oxygen required?
Yes
Is oxygen required?
No
Does this relate to an unchanged chronic condition, or new/acute?
Does this relate to an unchanged chronic condition, or new/acute?
New
Does this relate to an unchanged chronic condition, or new/acute?
Chronic
Is monitoring required?
Is monitoring required?
Yes
Is monitoring required?
No
What type of monitoring equipment or active care is required?
Metabolic or Neurological
Fluid Status / IV Monitoring
Cardiac or Respiratory Monitoring
Does the patient have impaired cognitive functioning (such as dementia or delirium) requiring supervision?
Does the patient have impaired cognitive functioning (such as dementia or delirium) requiring supervision?
Yes
Does the patient have impaired cognitive functioning (such as dementia or delirium) requiring supervision?
No
Does the patient's chronic condition require monitoring during transport?
Does the patient's chronic condition require monitoring during transport?
Yes
Does the patient's chronic condition require monitoring during transport?
No
CARDIAC MONITORING, Does the patient require cardiorespiratory support? (ECMO, IAB or ETT)
CARDIAC MONITORING, Does the patient require cardiorespiratory support? (ECMO, IAB or ETT)
Yes
CARDIAC MONITORING, Does the patient require cardiorespiratory support? (ECMO, IAB or ETT)
No
Does the IV only contain GTN, heparin or saline?
Does the IV only contain GTN, heparin or saline?
Yes
Does the IV only contain GTN, heparin or saline?
No
IV ADDITIVES, What is running in the IV?
*
IV REQUIREMENTS, Does IV require a syringe driver or infusion pump?
IV REQUIREMENTS, Does IV require a syringe driver or infusion pump?
Yes
IV REQUIREMENTS, Does IV require a syringe driver or infusion pump?
No
Infusion - Self Managed
Infusion - Self Managed
Yes
Infusion - Self Managed
No
Does the patient have an illness or disability that precludes them from utilising any other form of transport?
Does the patient have an illness or disability that precludes them from utilising any other form of transport?
Yes
Does the patient have an illness or disability that precludes them from utilising any other form of transport?
No
Please select appropriate option
Other
Severe disability
Falls Risk
Please provide details of illness or disability
*
Heart Rate
*
Respiration Rate
*
Blood Pressure
*
Conscious State(GCS)
*
O2 Sats
*
Billing Information
Reason for Transport
Inter-Hospital Transfer
Specialist Appointment
Respiratory
Renal
Rehabilitation
Oncology
Hospital Discharge
Hospital Admission
Emergency Department
Cardiac
Hyperbaric
Cystic Fibrosis
X-Ray / Radiology
Admission for day procedures
Day Leave
Compassionate
Specific Reason for Transport
Pacemaker
Cardiologist
Cardiac
Physiotherapy
Drug
Respiratory
Other Renal Appointment
Dialysis
Dressing Change
Hyperbaric Treatment
Pain Management
X-Ray
Urology
Hearing Services
Podiatry
Optical
Admission for Day Surgery
Radiation Therapy
Chemotherapy
Admission to another hospital
Pain Management
Urology
Hearing Services
Podiatry
Optical
Dental
Other Renal Appointments
Dialysis
Physiotherapy
Cardiac
Other
High Level Care (Nursing Home)
Admission for Day Surgery
Radiation Therapy
Chemotherapy
Other
Day Surgery
Cancer
Cardiac
Pacemaker
Admission
Cardiologist
Hyperbaric
Cystic Fibrosis
X-Ray / Radiology
Admission for day procedures
Respiratory
Hospital Discharge
Emergency Department
Oncology
Renal
None of the above
Is the patient already admitted to a public hospital or public emergency department?
Is the patient already admitted to a public hospital or public emergency department?
Yes
Is the patient already admitted to a public hospital or public emergency department?
No
Is the patient coming from a private facility?
Is the patient coming from a private facility?
Yes
Is the patient coming from a private facility?
No
Is the patient in a public non-admitted health care facility (includes urgent care centres and specialist clinics)?
Is the patient in a public non-admitted health care facility (includes urgent care centres and specialist clinics)?
Yes
Is the patient in a public non-admitted health care facility (includes urgent care centres and specialist clinics)?
No
Patient Billing Type
General / Patient / Private / AV Subscriber
Concession
WorkCover
TAC
DVA
Hospital
Concession Type
Pension
Health Care Card
Is the transport for a Public Health Appointment or Health Independence Program Appointment?
Is the transport for a Public Health Appointment or Health Independence Program Appointment?
Yes
Is the transport for a Public Health Appointment or Health Independence Program Appointment?
No
Reference Number
*
Hospital Billing Reference
*
I acknowledge that this booking for a non-emergency ambulance service (the Service) is made in accor
Booking Facility Details
Booking Facility
*
Contact Name
*
Contact Phone (Include Area code and phone number only)
*
Contact Email
*
*
Authorising Practitioner
*
Authorising Practitioner Phone (Include Area code and phone number only)
*
Patient's Title
Mr
Mrs
Ms
Dr
Miss
Patient's First Name
*
*
Patient's Last Name
*
*
Patient's Date of Birth
*
*
Patient's Age Years
*
Patient's Age Months
*
*
Patient's Gender
*
Male
Female
X (Unspecified/Indeterminate)
Weight
<= 159 kgs
160 kgs - 315 kgs
>= 316 kgs
Height
<= 182 cms
183 cms - 205 cms
>= 206 cms
Girth
<= 52 cms
53 cms - 80 cms
>= 81 cms
Escort
Escort
Yes
Escort
No
Escort Name
*
Relationship
*
Transport Platform
Please confirm patients mobility
Please confirm patients mobility
Patient is able to walk and climb three steps unaided
Please confirm patients mobility
Patient is able to walk and climb three steps with assistance
Please confirm patients mobility
Patient mobility is restricted to a wheelchair and transport must be completed in a hoist equipped vehicle (not a falls risk)
Please confirm patients mobility
Patient requires stretcher as they are unable to walk and needs to lie down for transport
Equipment/Mobility Aids
Walking Frame
Wheelchair
Other
Please specify other equipment
*
What is the reason for stretcher requirement?
Comfort
Distance of travel
Pain management
Patient is bed bound
Humidicrib
Guide/Assistance Dogs (with declaration)
Other
What other requirements do you have?
*
Patient Pick-Up Location
*
*
This is a residential address
Additional location details
*
Ward Type
Oncology
Radiology
Emergency
Admissions
Other
Hospital Ward / Facility Name
*
Pick-Up Phone (Include Area code and phone number only)
*
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Ready for pick-up now (Your requested pickup time is not guaranteed)
Any booking outside business hours (7am and 6pm) for all regional locations are subject to ESTA's review and approval
Escort
Family
1 X Medical
2 X Medical
1 X Guard
2 X Guard
Essential Primary Carer
There is no Medical Escort available for this booking (High Acuity)
Patient Destination Location
*
*
This is a residential address
Additional location details
*
Ward Type
Oncology
Radiology
Emergency
Admissions
Other
Hospital Ward / Facility Name
*
Destination Phone (Include Area code and phone number only)
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Choose Return Trip Day
Choose Return Trip Day
Same day return
Choose Return Trip Day
Following day return
Return Trip Time
*
Is this a recurring appointment?
Is this a recurring appointment?
Yes
Is this a recurring appointment?
No
Recurring Trip 1
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Return Trip Time
*
Recurring Trip 2
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Return Trip Time
*
Recurring Trip 3
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Return Trip Time
*
Recurring Trip 4
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Return Trip Time
*
Recurring Trip 5
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Return Trip Time
*
Recurring Trip 6
Pick-Up Date
*
Pick-Up Time
*
Appointment Time
*
Return Trip Required?
Return Trip Required?
Yes
Return Trip Required?
No
Return Trip Time
*
Clinical Information
What is the patient's diagnosis/presenting problem?
Additional Diagnosis Details
*
Infections Disease
No Infectious Disease
MRSA
KPC
SAR
Influenza
COVID/Suspected COVID
Other – Please provide specific infectious disease information in ‘Other Transport or patient information’ section
Other transport or patient information
Please provide any other additional information that you deem is necessary relating to the patient or transport
*
Calculated fields
Acuity
*
Stretcher Type
*