Download Request Form for Transfer to Another Hospital

On October 1, 2017, part of the "Implementation Standards for the Transport and Acceptance of Patients" was revised in Tokyo.
When transferring a patient, 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, a new format has been adopted.

Download Form

PDF format

This is in PDF format, so please print it out for your use.
Note: We recommend using plain paper for printing, with print sizes A4 and B5.
Thermal printers cannot accept thermal paper.

• Transfer Hospitalization Request Form (PDF 341.5KB)

Word and Excel format

The files are in Word and Excel formats, so please print them out for use.
Note: It is recommended to use plain paper for printing, with print sizes of A4 and B5.
Thermal printers cannot accept thermal paper.

• Transfer Request Form (Word 52.4KB)