Skip links and keyboard navigation

Repatriation Request (Form E)

Repatriation Request (Form E)

Repatriation Request (Form E)

Section A - Patient details

(patient, HHS or specialist to complete)

Date of birth * (DD / MM / YY)
Date of death * (DD / MM / YY)
(Hospital / Facility name)
Does the deceased identify as being of Aboriginal or Torres Strait Islander descent?
Patient escort details
Date of birth * (DD / MM / YY)
Section B - Evidence

Please attach evidence to facilitate transport

Please attach evidence to facilitate transport
Section C - Return travel for Escort

(if travel not booked, specialist or treating HHS to complete)

Date ready to travel home * (DD / MM / YY)
Travel home time
Recommended return mode of travel:
Section D - Approving hospital details

(Home HHS)

Section E - Escort declaration

(Patient escort to complete)

The information provided is true and accurate at the time of application. I give my permission for Hospital and Health Service staff to obtain information about the deceased patient for the purpose of administering my application. I understand that the family of the deceased patient is responsible for making the transport arrangements with the Funeral Director in consultation with Hospital and Health Service staff. I understand that repatriation is for transportation costs and excludes costs associated with the funeral service.

Date * (DD / MM / YY)
Hospital and Health Service use only

I, as the medical superintendent (or representative), authorise the above transport as required.

Date * (DD / MM / YY)