Stanly County EMS - Non-Emergency Transport Scheduler

Transport is subject to final approval of Stanly County EMS. We will contact the contact person listed below if the transport is denied or cancelled.

Person Completing This Form

Your Full Name *

Caller / Contact Information

Contact Name *

Phone Number *

Relationship to Patient *

Patient Information

First Name *

Last Name *

Date of Birth *

Weight in KG * Approximate weight in kilograms (required)

Transport Date & Time

Requested Transport Date * Select a date to see available time slots

Available Time Slots *

Please select a date above to view available slots.

Transport Details

Reason for Transport *

Pick-up Facility Name Optional — Select a facility to auto-fill the address, or choose "Other" to type one

Pick-up Location Address *

Pick-up Location Type *

Room Number

Destination Facility Name Optional — Select a facility to auto-fill the address, or choose "Other" to type one

Destination Location Address *

Medical Equipment

Does the patient require Oxygen or any other Medical Equipment during transport? *

No Yes

Insurance Information

Is insurance information being provided? *

No Yes

Additional Information

Notes / Special Instructions

Attach PCS (Physician Certification Statement) * Required — Accepted: PDF, JPG, PNG, DOC, DOCX (max 10MB)

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Pending

-

Approved

-

Denied

-

Completed

-

Today's Transports

Transport Requests

ID	Submitted	Patient	Transport Date	Time Slot	Pick-up	Destination	Status	CAD
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Transport Archive

ID	Patient	Transport Date	Time Slot	Pick-up	Destination	Completed By	Completed On
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When	User	Action	Details
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