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Book 1

The document is a two-way referral form containing fields for patient information like name, age, address, medical history, diagnosis, treatment given and referrals. It allows specifying priority of referral and includes sections for details of the referring doctor and receiving doctor.

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catherine joy macalos
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29 views

Book 1

The document is a two-way referral form containing fields for patient information like name, age, address, medical history, diagnosis, treatment given and referrals. It allows specifying priority of referral and includes sections for details of the referring doctor and receiving doctor.

Uploaded by

catherine joy macalos
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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TWO WAY REFERRAL FORM

Type of Referral Priority or Emergency Non Emergency


Reasons for Referral _____________________________________________________________

Referred To_____________________________________________________________________
Patient's Category Health Insurance [specify] _ ____ Charity

Name of Patient's _______________________________________________________________


Age ___Sex_____Civil Status_____ Occupation ___________________ Religion______________
Address _______________________________________________________________________
Responsible Person ____________________________Relation _________________Tel./Cel.#____
Admitting impresion
_________________________________________________________________________________
Vital Signs BP_______HR?PR______RR_______ Temp________ Wt_______-Blood Type___________
Allergies_____________________Other Vital Sign ________________________________________
Abstract/History [may attach a separate sheet if necessary

Diagnostic Procedure done/Treatment Given [pls specify the date,dose,timelast given [may attach a
separate sheet if necessary]

Referred by:

___________________________________________________________________________________
Signature over Printed Name Desination Tel./Cel.#
______________

_____________
Pay

_____________
_____________
____________
____Tel./Cel.#____

_______________
d Type___________
_______________

given [may attach a

_________________

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