L-0.2, r. 1 - Regulation respecting the application of the Act respecting medical laboratories and organ and tissue conservation

Schedule Disposition versions

2012-09-01

SCHEDULE 7

(s. 232)

DECLARATION OF TRANSPORT BY AMBULANCE

DECLARATION OF TRANSPORT BY AMBULANCE
Identification
Name of person transported
Sex M c F c
Address
Telephone number
Age
Health Insurance No.
Name of ambulance service
Permit No.
Vehicle reference No.
Co-ordinates of transport
Date of call
Time of call
Time of taking in charge
Time of arrival at H.C.
Distance travelled with transported person
km
Taking in charge by the carrier
c Public lane
c Private residence
c Public building
c Work premises
c Hospital Centre
c Reception Centre
c LCSC
c Other
ZONE OF TAKING IN CHARGE
Identification of location where taken in charge
Address
Code for establishment that takes person in charge
Destination of the transported person
Name of establishment or other
Code for receiving establishment
Transfer by an establishment
Transfer by plane c
Helicopter c
Ambulance c
Other c
Name of escort
Transport
one-way c
return c
Reason for transfer
1- perinatality
2- neo-natality
3- for diagnosis
4- emergency
5- others
Amount to be paid by establishment to transfer $
Authorization of transfer
Justification
Date
Attending physician
Date
Director-general of H.C. or his representative
Date
Attendant’s signature
Signature of transport person or his escort or receiver
Reserved for carrier
ADM-307

R.R.Q., 1981, c. P-35, r. 1, Sch. 7.