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Non-Emer­gency Patient Trans­port (NEPT) Book­ing Request Form

This form is to be used to request Non-Emer­gency Patient Trans­port (NEPT) by ProMED Tas­ma­nia for patients who are med­ical­ly sta­ble and require trans­port between health­care facil­i­ties, to and from appoint­ments, or for dis­charge home. Please com­plete all manda­to­ry fields to ensure your book­ing can be processed with­out delay.

If you have any ques­tions about com­plet­ing this form, please con­tact us by phone on 1300 303 419 or by email at nept@​promedtas.​com.​au

If the book­ing request is from a health facil­i­ty with access to a Form 10A — Patient Assess­ment Record, please com­plete this doc­u­ment and email it to nept@​promedtas.​com.​au 

Patient Details

Please provide the Hospital/Facility ID where the patient is being treated or referred (if applicable).

Please provide the patient's first name, middle name (if applicable), and surname.

Please provide the patient's date of birth using the format DD/MM/YYYY.

Please provide the patient's street address, suburb, state, and postcode.

Please provide the patient's phone number.

Please provide the patients weight in kilograms (kg).

Patient Representative

If booking for yourself, please provide your own details.

If booking for yourself, please provide your own details.

If booking for yourself, please provide your own details.

If booking for yourself, please select "Self (Patient)".

Transport Details

Please provide the full name of the referring doctor, clinician, or healthcare facility (if applicable).

Please provide the facility name (if applicable), street address, suburb, state, and postcode.

Please provide using the format DD/MM/YYYY HH:MM.

Please provide the facility name (if applicable), street address, suburb, state, and postcode.

Please provide using the format DD/MM/YYYY HH:MM.

Select "Yes" if transport is required for the return journey, or "No" if only a one-way trip is needed.

Please provide the expected appointment length. If unsure, provide your best estimate or check with the treating facility.

Please provide the reason transport is required (e.g. specialist appointment, medical procedure, treatment, discharge).

Assessment of Patient

Please provide using the format DD/MM/YYYY HH:MM.

Please provide where the assessment was undertaken (e.g. home, facility, or clinic name).

A clinician is a Registered Medical Practitioner, Registered Nurse or Registered Paramedic.

Please provide first name and surname.

Please provide the patient's primary diagnosis or condition.

Indicate whether the patient has any known allergies or adverse reactions, including to medications, foods, latex, or other substances. If yes, record each allergen and the type of reaction below. If none, please write N/A.

Specify any existing conditions that may predispose patient to harm: 

Please list any other exsisting conditions not already listed.

Does the patient have any relevant comorbidities/medical conditions: 

Please list any other comorbidities/medical conditions not already listed.

Please indicate whether the patient's BGL is within their normal range.

Please provide using the format DD/MM/YYYY HH:MM.

Please provide the patient's latest BGL reading.

Please list any relevant instructions from the patient's ACD/MOLST (e.g. resuscitation preferences, treatment limitations, substitute decision-maker).

Does the patient have any invasive devices/management: 

Please list any other care or treatment not already listed.

Please indicate the Central Venous Access Devices (CVAD) type.

Invasive Device Observations - Access Device (CVAD/PIVC)
Device TypeInsertion DateIntegrity of Device SiteDevice Secure & Intact (Y/N)Date/Time Last AccessedAnticipated Care Required/Other Information

Please list every applicable device (one device per row).

Invasive Device Observations - Drain / Catheter (IDC/SPC/Drain)
Device TypeCurrent Drainage (mLs)Drainage Past 24hrs (mLs)Device Securement DetailsDevice Clamped (Y/N)Integrity of Device SiteAnticipated Care Required/Other Information

Please list every applicable device (one device per row).

Invasive Device Observations - Othe Devices (NGT/PEG/Trach)
Device TypeInsertion DateIntegrity of Device SiteDevice Securement DetailsDate/Time Last Accessed/Flushed/SuctionedAnticipated Care Required/Other Information

Please list every applicable device (one device per row).

Vacuum Assisted Closure Dressing Details
Date VAC CommencedDate of Last Dressing ChangeIntegrity of DressingIntegrity of VAC SystemPressure SettingsNo Active Management of VAC Required (Y/N)

Please list every applicable device (one device per row).

Please indicate the patient's oxygen delivery method.

Please provide the patient's current oxygen flow rate in litres per minute (LPM).

Please indicate whether the patient is receiving regular pain relief (Yes/No).

Please list the medications being provided, including name, dosage, frequency and last dose.

Please indicate whether pain relief is likely to be required during transport (Yes/No).

Please list the medications required, including name, dosage, and frequency.

Select Yes if the patient needs help taking, administering, or managing any medication during transport. Select No if the patient can manage their own medications independently.

Please list the additives in the intravenous therapy.

Intravenous Fluids / Elastomeric / Syringe Driver Details
Fluid TypeRateVolume Infused from Current Flask/SyringeVolume RemainingAdequate Volume for Transport (Y/N)TKVO/Pump/OffAnticipated Care Required/Other Information

Please indicate whether the patient is post-operative (Yes/No).

Please provide using the format DD/MM/YYYY.

Please indicate whether the patient is clinically stable and unlikely to deteriorate during transport (Yes/No).

Clinical Observations/Vital Signs

Vital Signs
Date/Time (24hr)Heart RateECG Rhythm (If Monitored)BPSpO2TempPain (0-10)Alert and Cooperative?

Please provide the patient's most recent vital signs, including date and time recorded

Please provide any comments on variations or trends in the patient's vital signs (e.g. recent fluctuations/changes). Leave blank if not applicable.

Equipment Requirements

Please indicate whether the patient exhibits signs or symptoms suggestive of an infectious disease that could be transmitted through airborne particles.

Select "Yes" if the patient requires a stretcher for transport, or "No" if they can be transported by wheelchair or walking.

Select "Yes" if the patient requires a wheelchair for transport, or "No" if they can walk independently or require a stretcher.

List any additional equipment needed (e.g. oxygen, cardiac monitor, bariatric equipment). Leave blank if not applicable.

List any specific needs or considerations (e.g. toileting assistance for long trips, interpreter required, hearing aids, fall risk precautions, dietary restrictions). Leave blank if not applicable.