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Hospital Transfer Form Template

Streamline the Process of Transferring Patients Between Hospitals

Transferring a patient can be a stressful process, often filled with logistical challenges. This Hospital Transfer Form Template is designed to help healthcare professionals streamline patient transfers, ensuring safety and clarity in communication. You can track medical histories, share vital information with receiving facilities, and minimize the risk of errors during the transfer process, all while adhering to compliance standards. Plus, the user-friendly design makes it easy for you to create, edit, and share forms as needed. Explore the live template to see how it works.

Use this Template (FREE) Live Preview
Patient full name
Date of birth
Medical record number (MRN)
Allergies (list reactions or write 'None')
Current diagnoses or reason for hospitalization
Gender
Woman
Man
Non-binary
Prefer to self-describe
Prefer not to say
Sending facility name
Sending clinician responsible for transfer
Sending clinician phone
Primary nurse/contact at sending facility
Receiving facility name
Receiving unit or service
Accepting provider name
Acceptance/bed secured confirmed
Yes
No
Transfer priority
Emergent
Urgent (within 4 hours)
Expedited (same day)
Routine (24-72 hours)
Scheduled (beyond 72 hours)
Requested transfer date
Mode of transport
Ground ambulance (ALS)
Ground ambulance (BLS)
Air ambulance
Wheelchair van
Stretcher van
Private vehicle
Other/Not applicable
Special transport requirements
Cardiac monitor
Oxygen
Ventilator
IV infusion pump
Isolation precautions
Restraints
None
Other
Please Specify:
Most recent vitals and clinical status
Key medications and last doses
Devices and lines in place
Infection risks and precautions
Please Specify:
Code status
Full code
DNR
DNI
DNR/DNI
Comfort measures only
Unknown
Not applicable
Primary reason for transfer
Please Specify:
Consent to release medical information and transfer granted
Yes
No
Relationship of person providing consent
Self
Parent/Guardian
Medical Power of Attorney
Spouse/Partner
Adult child
Not applicable
Other
Please Specify:
Name of person providing consent
Consent date
I certify the information provided is accurate
Yes
No
Primary emergency contact name
Emergency contact phone
Primary insurance
Emergency contact relationship to patient
Parent/Guardian
Spouse/Partner
Child
Sibling
Friend
Caregiver
Other
Please Specify:
{"name":"Patient full name", "url":"https://www.quiz-maker.com/QPREVIEW","txt":"Patient full name, Date of birth, Medical record number (MRN)","img":"https://www.quiz-maker.com/3012/images/ogquiz.png"}
Paper art illustration depicting a hospital transfer form layout for FormCreatorAI article

When to use this form

Use this form when you need to move a patient to a facility with available beds, specialized services, or closer-to-home care. It works for an ER sending a stroke patient to a neuro ICU, a rural unit arranging pediatric surgery at a tertiary center, or a stable patient requesting a move to their network facility. The form captures clinical status, accepting provider details, and transport needs so you can coordinate faster and avoid handoff gaps. Attach key documents, such as a Medical record release form to share records and a Hospital discharge form to summarize care and medications.

Must Ask Hospital Transfer Questions

  1. What is the clinical reason for the transfer and the required level of care?

    This clarifies urgency and the right destination (e.g., step-down, ICU, trauma), which speeds acceptance. It also helps assign the proper transport team and equipment.

  2. Which receiving facility has accepted the patient, and who is the accepting clinician with contact details?

    Admission cannot proceed without acceptance; these details enable a direct handoff and reduce call-backs. Accurate contacts prevent delays during transport and arrival.

  3. What are the current vitals, supports (oxygen, drips, devices), and any isolation or infection precautions?

    This snapshot tells the receiving team how to prepare rooms, PPE, and transport equipment. If screening applies, attach results via the COVID-19 Test result reporting form or include a Public health travel declaration form when required.

  4. Has the patient or legal representative provided consent and authorized release of records?

    Documented consent protects you and the patient and avoids last-minute disputes. It also ensures you can share charts, labs, and imaging with the receiving team.

  5. What documents are attached, and what are the target pickup time and mode of transport?

    Clear attachments (summary, medication list, imaging) prevent missed information on arrival. A specific time and mode (ground, critical care, air) let teams schedule staff and prepare.

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