Request Patient Report Forms

A Patient Report Form (PRF) may be requested from ER24 by a patient, legal representative / power of attorney or legal guardian.

Patient Report Forms are considered to be medico-legal documentation. Medico-legal documentation may only be released with explicit written consent from the patient, legal representative / power of attorney or legal guardian, or upon order of a court and legal investigations.

Please ensure all of the required information is completed in the form below. Incorrect and incomplete information may result in a delay to release documentation.

Please enter the name of the person requesting the documentation in the required field.
Please enter the telephone number of the person requesting the documentation.
Please enter your email address in the required field.

Please select in which capacity the documentation is requested (by the patient self, power of attorney, court order, etc.)

Please indicate your relationship to the patient or state the entity from which you are requesting the documentation.
Please enter the date when the incident was serviced.
Please enter the time when the incident was serviced.
Please enter the address where the patient was picked up.
Please indicate where the patient was transported to. In the case where a patient was not transported to any facility, please indicate reason.

In which Province was the patient collected or picked up?

Please select the Province in which the incident was serviced.
Please indicate in which town the incident was serviced.
Please enter the patient's first name.
Please enter the patient's last name.
Please enter the patient's ID number. If an ID number is not available or in case of a foreign patient, please enter Passport number or full date of birth.
Please enter the physical address of the patient's residence.
This field is required.
This field is required.