Self Assessment
Choose Consent Form
Informed Consnet for Ambulance Transfer
INFORMED CONSENT FOR AMBULANCE TRANSFER
Patient Name:
Reg. No.:
Date of Birth:
Nationality:
Sex:
Emirates ID/ Passport:
Visit Date:
App Time :
Mobile:
Date & Time of Transfer
Nationality:
Name of Referring Facility:
I
(relationship)
understand that the Faith Healthcare group ambulance intends to transfer me to
for further care.
I have been informed that the reason for transfer is as follows:
I have been informed of the following risks and/or benefits of this transfer:
The above information has been fully explained to me and I
Agree
Disagree to be Transferred.
Date
Time
Name
Signature
Patient/Guardian with relationship :
Doctor/MRP :
Witness :
Parent or Gaurdian Name (if patient is minor) :
Patient Signature
Witness Signature
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