Chelsea and Westminster Hospital
NHS Foundation Trust
OSL	
Logistical Solutions
To the Public Sector

C&W HOSPITAL TRANSPORT FAX (IN HOURS) 020 8746 8099	
	
Name	«PATIENT_Forename1» «PATIENT_Surname»	Hospital Number	     	
Tel No	«PATIENT_Main_Comm_No »	DoB	«PATIENT_Date_of_Birth»	
Collection Point
(Usually Patient Home Address)
Postcode essential	     	Destination Address
Postcode essential	     	
DAY Required		Time of appt	     	
DATE Required	     	Repeat When?	     	
							Appointment Type:	
Carer Escort	Yes      No 	OPD			Discharge		
Medical Escort	Yes      No 	Admission			Transfer		
	Other	     	

10/A

	Patient is able to get into car with assistance of driver only for walking
(1 seat, non Amb Person)		32/S
	Patient needs to lie down or sit with legs straight on  a stretcher with assistance of driver & attendant
(3 seats, 2 Amb Persons)		
11/B
	Patient needs to travel in an ambulance with assistance of driver for walking
(1 seat, 1 Amb Person)		41/E

	Patient needs to travel in an ambulance with ramp/tail lift, with the assistance of driver only, travelling in own wheelchair
(4 seats, 1Amb Person)		
12/C

	Patient needs to travel in ambulance with assistance of driver and attendant e.g. for carrying patient over steps in carrying chair
(1 seat, 2 Amb Persons)		42/G

	Patient needs to travel in an ambulance with ramp/tail lift, with assistance of driver and attendant, travelling in own wheelchair.
(4 seats, 2 Amb Persons)		
15/K

	Patient needs to travel in ambulance with ramp/tail lift with the assistance of driver only travelling in ambulance chair
(1 Amb Person)		62/H

	Patient requires exclusive use of ambulance. To be used only with authorisation of a doctor or consultant. Eg terminally ill patients
(3 seats, 2 Amb Persons)		

DOES THE PATIENT HAVE ANY OTHER REQUIREMENTS – PLEASE US FURTHER INFORMATION BELOW
Oxygen LTS?		DNR – Letter		Own Zimmer		
LV Drip		Infectious?		Own Electric Wheelchair		
Heavy Patient (over 15 Stone)		SCBU		Full Length Plaster		
House Keys		Child Car Seat		Wheelchair Required		

Further Information:      

Transport Requested by:      

Extension Number:      

Signature