Request for non-emergency transfer

Contact Information

Patient Information
Do you have an OHIP number?

Pickup information

Transfer Information
Returning same day?
Does the person have a valid DNR Confirmation Form?
Does the persons require isolation protocols?
Does the person have a new or worsening cough?
Feeling feverish or had shakes or chills in the last 24 hours?
Have a headache, sore throat, muscle pain, abdominal pain, vomiting, diarrhea?

Outbreak Information
Does the sending or receiving facility have a reported outbreak?
Outbreak status:
Outbreak type:

Ambulance Transport
Patient is in an unstable medical condition at risk of changing status
Patient requires medical monitoring by a paramedic during transport
Patient requires a stretcher