Quotation Request – Health Select Services

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Quotation Request

All quote requests must be made at least 2 business days prior to the requesting transport date.

Please note, Health Select does not quote requests in the hospital setting where the responsibility for payment sits with the hospital, in accordance with the Ambulance Services Payment Guidelines.

Please complete the below details to the best of your ability.
You will be emailed a copy of the details provided to the contact email address provided.

Your Contact Details:
Contact Name:*
Contact Number:*
Contact Email*
Preferred Contact Method*
Please confirm if the transport is not medically necessary.*
- Medically necessary.
- Not medically necessary.
If the transport is medically necessary, it is usually the responsibility of the hospital/facility to organise transport. Please tick the following box to continue.
- I confirm we need to proceed with a quote for transport.
Patient Details:
Name*
Surname Firstname
Date of Birth:*

Day
Month
Year
Gender:*
Patient Weight:*
Approximate Weight:*
Patient Girth:*
Ie, Hip to Hip measurement / widest body point measurement.
UR Number (if known):
Patient Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Is the patient a recipient of the pension?*
- Yes
- No
Is the patient a member of Ambulance Victoria?*
- Yes
- No
Is the patient a member of DVA?*
- Yes
- No
Responsible Party:
Responsible Party
Please Specify*
Claim/Order Number*
Who should the invoice be made out to?*
Transport Details:
Transport Mode*
Transport Type:*
Wait & Return*
Does the patient require clinical supervision during the appointment?
NB: additional charges apply.
Date of Transfer*
DD slash MM slash YYYY
Day of Transfer
Day of Transfer
Day of Transfer
Day of Transfer
Day of Transfer
Day of Transfer
Day of Transfer
Pick Up Time:*

: Hours

Minutes

AM/PM
Appointment Time (if applicable):

: Hours

Minutes

AM/PM
Does the Patient require Multiple Bookings?*
- Yes
- No
Number of Bookings Required?*
Additional Transport Details:
Date of Transfer*
DD slash MM slash YYYY
Pick Up Time:*

: Hours

Minutes

AM/PM
Appointment Time (if applicable):

: Hours

Minutes

AM/PM
Date of Transfer*
DD slash MM slash YYYY
Pick Up Time:*

: Hours

Minutes

AM/PM
Appointment Time (if applicable):

: Hours

Minutes

AM/PM
Date of Transfer*
DD slash MM slash YYYY
Pick Up Time:*

: Hours

Minutes

AM/PM
Appointment Time (if applicable):

: Hours

Minutes

AM/PM
Date of Transfer*
DD slash MM slash YYYY
Pick Up Time:*

: Hours

Minutes

AM/PM
Appointment Time (if applicable):

: Hours

Minutes

AM/PM
Origin/Destination Details:
Origin Location Type*
- Hospital/Facility
- Private Address
Hospital/Facility Name:*
Ward/Department:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Phone:*
Access Requirements:*
As the origin is a Private Address, are there any access issues we should know about? eg, Stairs or Vehicle Parking.
Destination Location Type*
- Hospital/Facility
- Private Address
Hospital/Facility Name:*
Ward/Department:
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Contact Phone:*
Access Requirements:*
As the destination is a Private Address, are there any access issues we should know about? eg, Stairs or Vehicle Parking.
Clinical Details:
Patient Diagnosis:*
Clinical care required during transport*
- None
- IV Therapy
- Oxygen Therapy
- Cardiac Monitor
- Pulse Oximetry
- BSL Monitoring
- Infection Control
- Other
IV Therapy Contents*
Oxygen Therapy Litres*
Oxygen Therapy Via*
Please specify Infection Control:*
Please Specify Other*
Additional Information:
Will anyone be accompanying the patient during transport?*
- Yes
- No
Escort Type:*
Additional Information:
Name
This field is for validation purposes and should be left unchanged.

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