Pre-Hospital Care Form (1x.2025)

Basic Information

Date

Departure Time

Arrival Time

Vehicle Used

Ambulance

Fire Truck

Others

Arrival at Scene - Location

Arrival at Scene - Time

Departure from Scene - Location

Departure from Scene - Time

Arrival at Hospital - Name

Arrival at Hospital - Time

Departure from Hospital - Location

Departure from Hospital - Time

Arrival at Station

Driver

Persons Present Upon Arrival

Police

Barangay Officials

Relatives

Bystanders

None

Patient Information

Patient Name

Date of Birth

Age

Gender

Male

Female

Civil Status

Single

Married

Address

Zone

Occupation

Place of Incident

Zone/Landmark

Time of Incident

Informant Details

Informant Name

Informant Address

Walk In / Call

Walk In

Call

Call/Arrival Time

Contact Number

Relationship to Victim

Personal Belongings Hold Ctrl/Cmd to select multiple items

Other Belongings (specify)

Team Leader Notes

Team Information

Team Leader

Data Recorder

Logistic

1st Aider

2nd Aider

Hospital Endorsement

Endorsement

Hospital Name

Received by (Signature)

Signature over printed name

Date & Time

WAIVER - REFUSAL OF TREATMENT/TRANSPORTATION

I, the undersigned have been advised that assistance on my behalf is necessary and refusal of assistance and/or transportation for further treatment may result in death or impair my health condition. Nevertheless, I refuse to accept treatment and/or transport and assume all risks and consequences of my decision and release the Rescue 118 responders from any liability arising from any delay or refusal.

Patient Name & Signature

Patient signature

Witness Name & Signature

Witness signature

Ready to Submit

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PRE-HOSPITAL CARE FORM

Interactive Injury Mapping

FOR Stroke Victim - F.A.S.T. Assessment

FOR OB Patients Only

WAIVER - REFUSAL OF TREATMENT/TRANSPORTATION

Ready to Submit