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Transportanfrage Auftraggeber Name oder Institutionsname * Adresse * Adresse Adresse Adresse PLZ PLZ Ort Ort Land AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Land Email * Telefon * Kostengarant (Wer ist der Rechnungsempfänger) Firma / Instutition * Versicherungsnummer * Vor- und Nachname Vor- und Nachname Vornanme Vornanme Nachnanme Nachnanme Fallnummer Adresse * Adresse Adresse Adresse PLZ PLZ Ort Ort Land AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Land Email * Telefon: * Patientenangaben Patientenname * Patientenname Vorname Vorname Nachname Nachname Geburtsdatum * Risikopatient: Herzschrittmacher (Implant. Def.) Vorbelastungen / Diabetes, uvm. Geschlecht * Männlich Weiblich Divers Patientenfallnummer Kostenstelle Transportart: Liegendtransport Im eigenen Rollstuhl Rollstuhl mitbringen Sitzend Infusion Zusätzliches mat./Pers.: Begleitfahrzeug für Gepäck & Personen Zweite med. Fachperson Begleitperson dabei Gepäck (Volumen/kg?) Tragestuhl für Transfer zur Trage (2. Fachperson erforderlich) Isolation (Covid, etc.) Pat. Informationen: Akten Patient über 100kg (Angabe unten) Sauerstoff l/min (Angabe unten) Urologischer Katheter Vakummatratze Überwachung Vitalfunktionen Pat. mit Tracheastoma Gewicht des Patienten (kg): Benötigter Sauerstoff l/min: 1. Anhang / Datei (optional) Drop a file here or click to upload Datei wählen Maximum file size: 5MB 2. Anhang / Datei (optional) Drop a file here or click to upload Choose File Maximum file size: 5MB Bemerkung / Ergänzungen: Transporttermin Wochentag Montag Dienstag Mittwoch Donnerstag Freitag Samstag Sonntag Datum Hinfahrt: Datum Rückfahrt: Hinfahrt (Abholzeit): * 00:0000:0500:1000:1500:2000:2500:3000:3500:4000:4500:5000:5501:0001:0501:1001:1501:2001:2501:3001:3501:4001:4501:5001:5502:0002:0502:1002:1502:2002:2502:3002:3502:4002:4502:5002:5503:0003:0503:1003:1503:2003:2503:3003:3503:4003:4503:5003:5504:0004:0504:1004:1504:2004:2504:3004:3504:4004:4504:5004:5505:0005:0505:1005:1505:2005:2505:3005:3505:4005:4505:5005:5506:0006:0506:1006:1506:2006:2506:3006:3506:4006:4506:5006:5507:0007:0507:1007:1507:2007:2507:3007:3507:4007:4507:5007:5508:0008:0508:1008:1508:2008:2508:3008:3508:4008:4508:5008:5509:0009:0509:1009:1509:2009:2509:3009:3509:4009:4509:5009:5510:0010:0510:1010:1510:2010:2510:3010:3510:4010:4510:5010:5511:0011:0511:1011:1511:2011:2511:3011:3511:4011:4511:5011:5512:0012:0512:1012:1512:2012:2512:3012:3512:4012:4512:5012:5513:0013:0513:1013:1513:2013:2513:3013:3513:4013:4513:5013:5514:0014:0514:1014:1514:2014:2514:3014:3514:4014:4514:5014:5515:0015:0515:1015:1515:2015:2515:3015:3515:4015:4515:5015:5516:0016:0516:1016:1516:2016:2516:3016:3516:4016:4516:5016:5517:0017:0517:1017:1517:2017:2517:3017:3517:4017:4517:5017:5518:0018:0518:1018:1518:2018:2518:3018:3518:4018:4518:5018:5519:0019:0519:1019:1519:2019:2519:3019:3519:4019:4519:5019:5520:0020:0520:1020:1520:2020:2520:3020:3520:4020:4520:5020:5521:0021:0521:1021:1521:2021:2521:3021:3521:4021:4521:5021:5522:0022:0522:1022:1522:2022:2522:3022:3522:4022:4522:5022:5523:0023:0523:1023:1523:2023:2523:30 Terminzeit vor Ort: 00:0000:0500:1000:1500:2000:2500:3000:3500:4000:4500:5000:5501:0001:0501:1001:1501:2001:2501:3001:3501:4001:4501:5001:5502:0002:0502:1002:1502:2002:2502:3002:3502:4002:4502:5002:5503:0003:0503:1003:1503:2003:2503:3003:3503:4003:4503:5003:5504:0004:0504:1004:1504:2004:2504:3004:3504:4004:4504:5004:5505:0005:0505:1005:1505:2005:2505:3005:3505:4005:4505:5005:5506:0006:0506:1006:1506:2006:2506:3006:3506:4006:4506:5006:5507:0007:0507:1007:1507:2007:2507:3007:3507:4007:4507:5007:5508:0008:0508:1008:1508:2008:2508:3008:3508:4008:4508:5008:5509:0009:0509:1009:1509:2009:2509:3009:3509:4009:4509:5009:5510:0010:0510:1010:1510:2010:2510:3010:3510:4010:4510:5010:5511:0011:0511:1011:1511:2011:2511:3011:3511:4011:4511:5011:5512:0012:0512:1012:1512:2012:2512:3012:3512:4012:4512:5012:5513:0013:0513:1013:1513:2013:2513:3013:3513:4013:4513:5013:5514:0014:0514:1014:1514:2014:2514:3014:3514:4014:4514:5014:5515:0015:0515:1015:1515:2015:2515:3015:3515:4015:4515:5015:5516:0016:0516:1016:1516:2016:2516:3016:3516:4016:4516:5016:5517:0017:0517:1017:1517:2017:2517:3017:3517:4017:4517:5017:5518:0018:0518:1018:1518:2018:2518:3018:3518:4018:4518:5018:5519:0019:0519:1019:1519:2019:2519:3019:3519:4019:4519:5019:5520:0020:0520:1020:1520:2020:2520:3020:3520:4020:4520:5020:5521:0021:0521:1021:1521:2021:2521:3021:3521:4021:4521:5021:5522:0022:0522:1022:1522:2022:2522:3022:3522:4022:4522:5022:5523:0023:0523:1023:1523:2023:2523:30 Rückfahrt (Uhrzeit): 00:0000:0500:1000:1500:2000:2500:3000:3500:4000:4500:5000:5501:0001:0501:1001:1501:2001:2501:3001:3501:4001:4501:5001:5502:0002:0502:1002:1502:2002:2502:3002:3502:4002:4502:5002:5503:0003:0503:1003:1503:2003:2503:3003:3503:4003:4503:5003:5504:0004:0504:1004:1504:2004:2504:3004:3504:4004:4504:5004:5505:0005:0505:1005:1505:2005:2505:3005:3505:4005:4505:5005:5506:0006:0506:1006:1506:2006:2506:3006:3506:4006:4506:5006:5507:0007:0507:1007:1507:2007:2507:3007:3507:4007:4507:5007:5508:0008:0508:1008:1508:2008:2508:3008:3508:4008:4508:5008:5509:0009:0509:1009:1509:2009:2509:3009:3509:4009:4509:5009:5510:0010:0510:1010:1510:2010:2510:3010:3510:4010:4510:5010:5511:0011:0511:1011:1511:2011:2511:3011:3511:4011:4511:5011:5512:0012:0512:1012:1512:2012:2512:3012:3512:4012:4512:5012:5513:0013:0513:1013:1513:2013:2513:3013:3513:4013:4513:5013:5514:0014:0514:1014:1514:2014:2514:3014:3514:4014:4514:5014:5515:0015:0515:1015:1515:2015:2515:3015:3515:4015:4515:5015:5516:0016:0516:1016:1516:2016:2516:3016:3516:4016:4516:5016:5517:0017:0517:1017:1517:2017:2517:3017:3517:4017:4517:5017:5518:0018:0518:1018:1518:2018:2518:3018:3518:4018:4518:5018:5519:0019:0519:1019:1519:2019:2519:3019:3519:4019:4519:5019:5520:0020:0520:1020:1520:2020:2520:3020:3520:4020:4520:5020:5521:0021:0521:1021:1521:2021:2521:3021:3521:4021:4521:5021:5522:0022:0522:1022:1522:2022:2522:3022:3522:4022:4522:5022:5523:0023:0523:1023:1523:2023:2523:30 Warten vor Ort: Ja Nein Abholadresse * Abholadresse Abholadresse Abholadresse PLZ PLZ Ort Ort Land AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Land Ziel-/Terminadresse: * Ziel-/Terminadresse: Ziel-/Terminadresse: Ziel-/Terminadresse: PLZ PLZ Ort Ort Land AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Land Begleitperson Begleitperson Vornanme Vornanme Nachname Nachname Telefon Begleitperson: Rechtliches * Die AGB und Datenschutzbestimmungen habe ich akzeptiert. 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