Emergency Ambulance Form

Medivac

Emergency Ambulance Form

PART I: Caller Information and Incident Details

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Quotation Number(Required)

Email(Required)

Name of Caller(Required)

Contact Number(Required)

Pick Up Location(Required)

Street Name ZIP / Postal Code Country

PART II: General Questions

BASE FEE

The base fee includes the evaluation of the patient by the ambulance crew. If first aid or treatment is necessary, additional charges will apply.

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Price(Required)

MIN WAITING TIME:

The minimum waiting time provided is an estimate and may vary depending on traffic and weather conditions.

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Min. Waiting Time(Required)

Base Fee for Medical Transport Service

Price: $ 0.00

Q1 ) What is the patient’s estimated weight ?

* Please be advised that additional charges will be incurred. The Paramedic will advise you accordingly.

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Additional Charges (Weight)

Price: $ 0.00

Q2 ) Does the patient be required to be carried down and/or up to another level ?(Required)

Yes

* Please be advised that additional charges will be incurred. The Paramedic will advise you accordingly.

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Additional Charges (People Carrying)

Price: $ 0.00

Q3 ) Does the patient require Oxygen and/or currently experiencing breathlessness ?(Required)

Yes

* Please be advised that additional charges will be incurred. The Paramedic will advise you accordingly.

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Additional Charges (Require Oxygen)

Price: $ 0.00

Q4 ) Is the patient experiencing any pain ?(Required)

Yes

* Please be advised that additional charges will be incurred. The Paramedic will advise you accordingly.

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Additional Charges (Pain)

Price: $ 0.00

Q5 ) Is there any change of behaviour and/or change in level of consciousness and/or experiencing any weakness ?(Required)

Yes

* Please be advised that additional charges will be incurred. The Paramedic will advise you accordingly.

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Additional Charges (Behaviour/Consciousness/Weakness Changes)

Price: $ 0.00

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Total Bill Estimator

PART III: Financial Counselling

To : MEDIVAC EMERGENCY AMBULANCE SERVICE P/L
202320939D

This is to confirm that I :-

had been informed that : -

The base fee for Ambulance is SGD
Additional charges will be payable for medication(s), consumable(s), and use of equipment(s) for continuous monitoring and/or care of the patient (“Additional Charges”). Such additional charges can only be determined after assessment of the patient by the ambulance crew.

Based on the triage over the phone ,estimate ambulance bill size is approximately to $680.00
The bill estimate is based on the information we received during the phone conversation and through our triage questions. The estimate may increase if the patient's condition worsens and/or if the information provided is inaccurate.

I further agree and consent for the ambulance crew to proceed with all necessary treatment for the patient and agree to the charges which are set out in the Additional Charges (“PART II”). I understand that in the event of a critical medical emergency during transportation, there might be a threat to the patient’s life, and there may be insufficient time for the ambulance crew to seek further consent from me. In such an event, I hereby also consent to all further necessary and required procedures/treatment to be utilized on an urgent basis to preserve the patient’s life and well-being. In such an event, I agree and consent to the payment of all additional emergency procedures/treatments utilized.

The waiting time for the ambulance is at least

No cancellation is allowed while the ambulance is proceeding to your location. Should the patient's condition deteriorate, do call us at (+65) 6100 6910. Patients with life-threatening emergencies, deemed by the ambulance crew, shall be conveyed to the nearest emergency department.

Payment of service shall be made immediately upon delivery of service through Bank transfer (i.e., PayNow).

This Agreement shall be deemed to be made under and governed by the laws of the Republic of Singapore in all respects, including matters of construction, validity, and performance.

In the event of any dispute arising out of the Agreement, all parties shall submit such disputes for resolution pursuant to the exclusive jurisdiction of the Courts of Singapore.

I hereby agree to your terms and conditions and confirm that I have been informed of your base fees and additional charges as follows :

PART I : BASE FEE

PART II : ADDITIONAL CHARGES (if applicable)

Additional charges will be applicable as follows:

ADD ON CHARGES / INVESTIGATIONS
Doctor Escort Provision of a medical escort during transport.	S$ 450 per hour
Doctor (Emergency Medicine Specialist) Escort Escort provided by an Emergency Medicine Specialist for mechanically ventilated patients or patients requiring BIPAP in ambulance.	S$ 550 per hour
Provision of Oxygen Supply of oxygen for patients requiring respiratory support.	S$ 80 per hour block
CPAP Mask Continuous Positive Airway Pressure (CPAP) mask for respiratory assistance.	S$ 550 per patient
Bariatric Patients Patients weighing 80 kg or more	S$ 50
Staircase Surcharge For transporting a patient up or down stairs in the absence of an elevator	S$ 20 S$ 25 per HDB Level or per 16 steps
12 Lead ECG Electrocardiogram (ECG) for heart monitoring and diagnostic purposes.	S$ 40 per patient
Invasive Procedures ● Advanced Airways ● Intravenous (IV) Access ● Oral Suctioning	S$ 50 per procedure
IV Medications or Penthrox Administration of intravenous medications or Penthrox for pain management.	S$ 90 per patient
Waiting Time Per 30 mins block after 30 mins	S$ 60 for every 0.5 hours
Pacing/Defibrillation Pads Use of pacing or defibrillation pads for cardiac emergencies.	S$ 180 per patient
Resuscitation Attempts Including the use of defibrillator pads, mechanical CPR, and/or ETCO2 monitoring.	S$ 650 per patient
Provision of Mechanical Ventilator on board Ambulance ● Invasive Ventilation ● Non-Invasive Ventilation (e.g CPAP, BiPAP, HFNC)	S$ 480 per hour block
Provision of Syringe Pump and Infusion Pump For the administration of medications and fluids.	S$ 180 per hour block
Medical Escort Services Provision of a medical escort during transport. Minimum 3 hours	S$ 40 per hour (Office hours) S$ 60 per hour (After Office Hours)

*Note : The parties agree that to the extent they sign electronically, their electronic signature is the legally binding equivalent to their handwritten signature.

Signed and Agreed By :

Client's Agree(Required)

I Agree

Please sign below indicating that you read and agree to the service agreement :

Client's Signature(Required)

Emergency

(+65) 6100 6910

Operating Hours

24 Hours

Email

enquiry@emergencyambulance.com.sg

Medivac