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This form is intended for use by Healthcare Facilities in and around the Hawke's Bay region of New Zealand.

Questionnaire

Inter-facility and non-emergency patient transport

Questionnaire - 10 questions
File Size:	900 kb
File Type:	pdf

Please fill in the form below and then press submit (or download the pdf to the right, fill in and return via email).

We appreciate your help

* Indicates required field

Facility Name (required) *

Email (not required) *

What is the approximate number of residents at your facility? *

Does your facility currently use a Patient Transport/Transfer service? *

Yes No

If yes, do you require patients to be transported by ambulance, mobility vehicle or car? (Mark any that are appropriate) *

Ambulance Mobility Vehicle Car

How often would you require each service?

Ambulance (number of times per week) *

Mobility Vehicle (number of times per week) *

Car (number of times per week) *

Is there a need for a healthcare professional to monitor these patients en-route? *

Yes No

Do you prefer to supply this member of staff or would you prefer the PTS provider to supply them? *

Own staff member PTS Provider

Do you require Paramedical Services on critical care patient transports? (eg ILS Paramedics, Intensive Care Paramedics) *

Yes No

Who is your current provider of non-emergency patient transport? *

Are you currently in an exclusive contract for this service? *

Yes No

Would you be open to contracting a local, private non-emergency patient transport service in the future? *

Yes No

Additional Comments *

Please feel free to add any feedback you may wish, including specific requirements

Submit

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