Email Validation

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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? YesDoes 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? YesIs 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? YesIs 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) YesHas 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 CrewDo you need a vehicle and/or driver or just a CAD number? CAD number only
Vehicle and/or Crew Vehicle and/or Crew Driver OnlyVehicle 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? YesIs 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? YesAre 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 YesI 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 YesI 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? YesDoes the patient require active clinical monitoring/care or clinical supervision during transport? No
Is oxygen required? Is oxygen required? YesIs 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? NewDoes this relate to an unchanged chronic condition, or new/acute? Chronic
Is monitoring required? Is monitoring required? YesIs 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 requiring supervision? Does the patient have impaired cognitive functioning requiring supervision? YesDoes the patient have impaired cognitive functioning requiring supervision? No
Does the patient's chronic condition require monitoring during transport? Does the patient's chronic condition require monitoring during transport? YesDoes 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) YesCARDIAC 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? YesDoes 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? YesIV REQUIREMENTS, Does IV require a syringe driver or infusion pump? No
Infusion - Self Managed Infusion - Self Managed YesInfusion - Self Managed No

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? YesIs 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? YesIs 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)? YesIs 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? YesIs 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 YesEscort No	Escort Name	Relationship

Transport Platform

Does the patient need a stretcher? Does the patient need a stretcher? YesDoes the patient need a stretcher? No
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
Equipment/Mobility Aids Walking Frame Wheelchair Other
Please specify other equipment
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? YesReturn Trip Required? No
Choose Return Trip Day Choose Return Trip Day Same day returnChoose Return Trip Day Following day return
Return Trip Time
Is this a recurring appointment? Is this a recurring appointment? YesIs this a recurring appointment? No

Recurring Trip 1

Pick-Up Date	Pick-Up Time	Appointment Time
Return Trip Required? Return Trip Required? YesReturn Trip Required? No	Return Trip Time

Recurring Trip 2

Pick-Up Date	Pick-Up Time	Appointment Time
Return Trip Required? Return Trip Required? YesReturn Trip Required? No	Return Trip Time

Recurring Trip 3

Pick-Up Date	Pick-Up Time	Appointment Time
Return Trip Required? Return Trip Required? YesReturn Trip Required? No	Return Trip Time

Recurring Trip 4

Pick-Up Date	Pick-Up Time	Appointment Time
Return Trip Required? Return Trip Required? YesReturn Trip Required? No	Return Trip Time

Recurring Trip 5

Pick-Up Date	Pick-Up Time	Appointment Time
Return Trip Required? Return Trip Required? YesReturn Trip Required? No	Return Trip Time

Recurring Trip 6

Pick-Up Date	Pick-Up Time	Appointment Time
Return Trip Required? Return Trip Required? YesReturn 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