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Home > Forms > Inter-facility Patient Transport Request

Inter-facility Patient Transport (IFT) Request

This form should be completed for inter-facility transfer (IFT) requests greater than 24 hours in advance of the scheduled appointment where the transport requires a ground ambulance, air ambulance or stretcher transport service. All patients must be medically stable.

Please ensure you make a note of your IFT-REQ # upon submission for future reference.

For same-day or unstable patients, or if you are unable to submit form below,
call the Virtual Emergency Care & Transfer Resource Service (VECTRS) 204-949-4000 to request the IFT.

Inter-facility Patient Transport Request

"*" indicates required fields

Step 1 of 3

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IFT-REQ

Submitter's Name*

Work Email*

(req. for confirmation of submissions)

Work Phone

Type of transfer request?*

New

Modification

Cancellation

Preferred Units of measure?*

Imperial (inches, lbs, etc.)

Metric (cm, kgs, etc.)

Does patient require a ground ambulance, air ambulance or stretcher transport service?*

Yes

NOTE: For other modes of transportation or commercial scheduled flights, please book through your regular pathways.

PATIENT INFORMATION

Patient Name*

First Last

Patient DOB (yyyy-mm-dd)*

YYYY dash MM dash DD

Does patient have a Manitoba PHIN number?*

Yes

PHIN Number*

Provide alternate health identification # or reason*

NEW TRANSFER

Appointment Type*

Appointment Date (yyyy-mm-dd)*

YYYY dash MM dash DD

Appointment Time (24-hr)*

Hours

Minutes

Other Appointment Type

ISO (Isolation) Requirement*

ACP (Advance Care Plan) Status*

Other ISO Requirement

Patient Weight (lbs)*

Patient Weight (kgs)*

NOTE: The weight value entered is greater than 250 lbs / 115 kgs. Please provide the following additional information:

Patient Height (inches)*

Patient Width (inches)*

Patient Circumference or girth (inches)*

Patient Height (cm)*

Patient Width (cm)*

Patient Circumference or girth (cm)*

SENDING SITE INFORMATION

Sending RHA / SDO*

Sending Site*

Sending Unit*

Sending Room*

Sending Unit Phone*

Referring Provider Name*

Referring Provider Call-back Number*

Is a medical escort required?*

Yes

Unsure

(Nurse / RT / PCP, etc.)

Is a non-medical escort required?*

Yes

Unsure

(family, guardian, friend, other)

NOTE: Further details on escort such as escort name and weight will be asked during triage the day prior to transport.

DESTINATION SITE INFORMATION

Destination RHA / SDO*

Destination Site*

Accepting Destination Provider*

Destination Unit*

Destination Room*

Destination Unit Phone*

EQUIPMENT REQUIRED

Equipment Required*

None

Cardiac Monitoring

Foley catheter

Other Tubes

Oxygen

Pump

Stretcher

Other

Note: Please specify the details of each equipment choice.

Other Tubes

Oxygen

Pump

Stretcher

Other Equipment

TRANSFER CANCELLATION

NOTE: For same day cancellations, call VECTRS 204-949-4000 to cancel the scheduled IFT.

Reason for Cancellation*

IFT-REQ #

Cancelled Appointment Destination RHA / SDO*

Cancelled Appointment Destination Site*

Cancelled Appointment Date (yyyy-mm-dd)*

YYYY dash MM dash DD

Cancelled Appointment Time (24-hr)*

Hours

Minutes

Cancellation Confirmation*

By Submitting Request you are confirming the cancellation and IFT will be deleted by VECTRS.

I confirm this cancellation request.

TRANSFER MODIFICATION

I need to modify the…

appointment date

appointment destination

appointment time

appointment type

IFT REQ #

Confirm Appointment Date (yyyy-mm-dd)*

YYYY dash MM dash DD

Confirm Appointment Destination RHA / SDO*

Confirm Appointment Destination Site*

Confirm Appointment Time (24-hr)*

Hours

Minutes

Confirm Appointment Type*

Confirm Accepting Destination Provider*

Confirm Destination Unit*

Confirm Destination Room*

Confirm Destination Unit Phone*

Name

This field is for validation purposes and should be left unchanged.

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