Download Request Form for Transfer to Another Hospital

On October 1, 2017, a part of the "Implementation Standards for the Transport and Acceptance of Patients" was revised in Tokyo.
When transferring to another hospital, please fill out the necessary information on the transfer request form and submit it to the arriving emergency team.
Additionally, due to changes in some content from October 1, 2019, we have updated to a new format.

Download Form

PDF format

It is in PDF file format, so please print it out for your use.
Note: It is recommended to use plain paper for printing, and the print sizes are A4 and B5.
Thermal printers cannot accept thermal paper.

• Transfer Hospitalization Request Form (PDF 341.5KB)

Word and Excel format

It is available in Word and Excel file formats, so please print it out for your use.
Note: It is recommended to use plain paper for printing, and the print sizes are A4 and B5.
Thermal printers cannot accept thermal paper.

• Transfer Request Form (Word 52.4KB)