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Get and Sign Ems Transfer of Care Form 2010-2022
Pain
Unresponsive
Suspected Injuries / Illnesses
EMS Treatment
Time
Medication
NOTES / COMMENTS
Dose
12-Lead ECG Delivered With Report
(Copy of each ECG REQUIRED)
Yes
IV
Fluid
Type:
EMS Provider Transferring Care
Provider Signature:
Bureau of Emergency Medical Services
Total IV Fluid
Volume Given:
Yes
mL
Care Transferred To:
Certification Number
(Another) EMS Agency/Service Name:
Date
Time
Receiving Facility (Hospital) Name:
Date
Time
Receiving Facility RN / PA / MD / DO...
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