INTER-MEDICAL UNIFIED SYSTEMS, INC

Medical Center Imus

AMBULANCE SERVICE
TRIP TICKET
Date__________
Transaction Number:_________________
Name of Patient: ____________________________________________
Age:________________
Sex:________________
Attending Physician: ________________________________________
Origin: ___________________________________________________
Destination:_______________________________________________
Reason for Transport: _______________________________________
Disposition:________________________________________________
Riders:____________________________________________________

Time Out: _________________ Time In:____________

Approved by: ________________________ MCI DOC 24 2017

INTER-MEDICAL UNIFIED SYSTEMS, INC

Medical Center Imus
AMBULANCE SERVICE
TRIP TICKET
Date__________
Transaction Number:_________________
Name of Patient: ____________________________________________
Age:________________
Sex:________________
Attending Physician:_________________________________________
Origin:_____________________________________________________
Destination:________________________________________________
Reason for Transport:________________________________________
Disposition:________________________________________________
Riders:____________________________________________________

Time Out: _________________ Time In:____________

Approved by: ________________________ MCI DOC 24 2017