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IMPORTANT: Please read through our Terms and Conditions of service before requesting cover (click this link to open a new page containing our terms and conditions)



Please complete the below fields to request cover for Medical Repatriation / Escort or to transfer a patient.

The fields marked as '*' are mandatory


Contact Information

Hospital / Company / Client Name (of person sending the request) *

Contact Name (of person sending the request) *

Email Address (of person sending the request) *

Contact Number (of person sending the request) *

Transfer Information

Patients Name*

Patients Date of Birth*

Patients Weight in Kg*

Patients Sex*

Male Female Other


Address of Pickup *

City *

Country *

Postal Code *

Address of Drop off *

City *

Country *

Postal Code *

Requested Dates

Date & Time

Transfer Urgency*

ASAP Routine Urgent Emergency / Critical Care

Additional Date / Time Information

Risk Assessment :

Specific Needs*

Mental Health Under Care Plan Under Protection Plan Dementia Learning Disability
Do Not Attempt Resus in place Physically Disabled Can be Aggressive Vulnerable Adult / Child None - Has capacity



Medical Staff Requirement *

Transport Attendant Emeregncy Medical Technician HCPC Registered Paramedic
NMC Registered Nurse Doctor Own Staff Supplied



Patient Group *

NICU / SCUBU Infant Peadiatric
Adult Elderly Mental Health ICT/ ITU



Type of Transfer *

Local UK National European
International Medical Escort Flight Repatriation



Family to Accompany*

Yes No



Medical Staff to Accompany*

Yes No



Patients Transfer Type / Mobility *

Walking
Wheelchair
Stretcher
Intubated / ICU/ ITU Other



Additional Needs

Oxygen
IV Medications
Infectious
Mental Health / Dementia
Bariatric
Non-Weight Bearing
Psychiatric
Other



Returning A B Medical Services Customer *

Yes
NO

Discount Code

Notes / Additional Information *

Person authorising Booking *

Data Protection Agreement

Please click below to consent to A B Medical Services (UK) Ltd holding data about this form and /or inquiries made hereafter in line with the current Data Protection / GDPR legislation. We are registered as a data controller / processor with the UK ICO. A B Medical Services (UK) Ltd will never use your data without consent and will never share this data without explicit consent. Please refer to our full Data Protection policy.

Terms and Condtions


Tick this box to confirm that you have read and accept our standard terms and conditions of service. These will become active at the point of accepting cover in writing or by e-mail with the operations department. Please note that our standard terms of business for payments / invoices are 14 days, a 20% charge will be added for late invoices / payments and by accepting cover, you are agreeing to these terms.

The above box must be accepted to submit your request