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IHT Form
Contact Person:  
Contact Number:  
Time:
Referring Facility:
Ward:
Referring Doctor:
Receiving Facility:
Ward:
Receiving Doctor:
Pick Up Time:
Appointment Time:
Patient Name:
Patient Surname:
ID Number/ Date of Birth:
Sex:
Age Group:
Medical Aid:
Medical Aid Number:
Admission Diagnosis:
Admission Date:
Baby Delivery?
Gestational Age:
Known Medical History:
Known Allergies:
Reason for Transfer:
Return Trip:
Main Member:
Main Member ID:
Attachments:
IV Lines:  
Catheter:  
Other Attachments:
Medication That Crew Will Monitor Or Administer:
Medication 1:
Medication 2:
Infusion:
Medication given to patient(IV,IM):
Vital Signs:
BP:
P:
RESP:
SATS:
TEMP:
GCS:
HGT:
HB:
O2:
Ventilated:

Any special requirements:
Ventilator Settings:
Mode:
FiO2:
RESP:
Peep:
Tidal Volume:
    
Minute Volume:
Peak Airway Pressure:
Pressure Support:
IE Ratio:
Sensitivity:
Special Requirements:
Syringe Driver:
 
Ventilator:
 Incubator:
Other Requirements:
Any Other Relevant Information:
The contents of this IHT (Inter-Hospital Transfer) Form and any attachments are confidential, and by submitting this form you confirm that you have the necessary authority to disclose the above patient information. The information completed will be sent directly to ER24’s Emergency Contact Centre. If you have submitted this transfer request in error, please notify the ER24 IHT Case Manager or ER24 Contact Centre Supervisor immediately. Please note that the applicant / sender must scan this form and any attached files for any errors prior to sending it through to ER24. Please note that the IHT request is not automatically approved and will be reviewed by the ER24 IHT Case Manager upon receipt. Please ensure that you contact the ER24 Contact Centre on 084 124 to confirm receipt of this IHT request.
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