RAAPID Repatriation/Transfer Request
Most Responsible Practitioner Information
Name (last, rst) Contact # Service/Specialty
Sending Facility Information
Facility Name Unit # Unit Phone #
**If Out-of-Province/
Country
Province/State City Country
Patient Information
Name (last, rst) Health Care# Date of birth (yyyy-mon-dd)
Care Information
Diagnosis at the time of repatriation/transfer Date of Admission
(yyyy-mon-dd)
Goal of Care Designation (Code Satus) Anticipated date of discharge (yyyy-mon-dd)
Recent surgeries, procedures, treatments
Please ensure repatriation planning is discussed with the patient and family
Contact Information
RAAPID North
Phone: 780.735.0400 Fax: 780.735.0114
RAAPID South
Phone: 403.944.4488 Fax:403-944-6707
Page 1 of 218565(Rev2017-07)
