Book Here

For Booking: Fill in the Form or call us directly on 03301 239996

Patient Details

Hidden

Unique ID

Age:(Required)

NHS number:(Required)

MHA Status: (Required)

If detained, section papers available?

Conveyance Details

Purpose of Conveyance:(Required)

Transfer or Discharge High Secure Ambulance for all transfers/Admissions

Has the patient consented for the conveyance?(Required)

Pick up date:(Required)

Pick Up address:(Required)

Pick up contact Tel: (Required)

Destination:(Required)

Destination postcode:(Required)

Destination contact Tel: (Required)

Will the patient require more than 2-person crew (Including Driver) & Why:(Required)

Mobility:(Required)

Currently RSTS does not provide service for Wheelchair/ Bed/ Stretcher bound patient

Vehicle Type: (High-secure cell or low-secure):(Required)

High Secure Ambulance for all patients detained under the Mental Health Act

Vehicle Type: (High-secure cell or low-secure):(Required)

High Secure Ambulance for all patients detained under the Mental Health Act

Any Medications to be transported with patient? If yes, please provide details.(Required)

Any self-administered medication such as asthma inhalers, Insulin pen, EpiPen

If, Control Drugs will be transported. the referring hospital will need to provide a Qualified Nurse - RMN.

Specific cultural, religious or faith requirements?(Required)

RISK (PLEASE REFER TO THE RISK MATRIX) To view Risk Matrix Click Here

View Key

Low

Medium

High

Harm to self

Harm to others

Absconsion

Medication

Physical Health

OTHER DETAILS TO INFORM THE RISK ASSESSMENT PROCESS

Medical Clearance given by the Medical/Clinical Team that the patient is medically fit to transfer:

(please include name and profession)

Covid-19 (Coronavirus) Status:(Required)

Additional INFORMATION / SPECIAL INSTRUCTION / ALLERGIES

Funding Information

Name, position & contact details of person completing this form:

Budget Code/Authorisation code (if applicable):(Required)

Funding Authority/ Trust:(Required)

Authorising Agent:(Required)

RSTS Booking Form

For Booking: Fill in the Form or call us directly on 03301 239996

Patient Details

Conveyance Details

RISK (PLEASE REFER TO THE RISK MATRIX) To view Risk Matrix Click Here

OTHER DETAILS TO INFORM THE RISK ASSESSMENT PROCESS

Funding Information