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Clinical Referral Form

The document is a clinical referral form that contains information about a patient being referred from one facility to another. It includes sections for patient details, chief complaints, medical history, physical exam findings, impressions, and reasons for referral. Upon discharge from the receiving facility, a return referral slip is to be filled out and sent back to the referring facility.

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bhssantonino
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33 views

Clinical Referral Form

The document is a clinical referral form that contains information about a patient being referred from one facility to another. It includes sections for patient details, chief complaints, medical history, physical exam findings, impressions, and reasons for referral. Upon discharge from the receiving facility, a return referral slip is to be filled out and sent back to the referring facility.

Uploaded by

bhssantonino
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CLINICAL REFERRAL FORM

___PHIC ___NON PHIC


Emergency Ambulatory Medico-Legal

Referred To: ______________________________________________ Address: ____________________________________________________


Date: ____________________________________________________ Time: _______________________________________________________
Name: ________________________________________________________________ Sex: _________ Age: ______ Birthday: _____________
(Surname) (First Name) (Middle Name)
Address: _______________________________________________________________________________________________________________
Chief Complaints: ______________________________________________________________________________________________________
Medical History: ________________________________________________________________________________________________________
HP1____________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________

Surgical Operation: No Yes if Yes, What Procedure? ________________________


Drug Allergy: No Yes if Yes, What? ___________________________________

Physical Examination: BP______ HR______ WT______ RR______ TEMP________


________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
______________________________________________________
Impression: ______________________________________________________________________________________
Action Taken:____________________________________________________________________________________
__________________________________________________________________________________________________

Reasons for Referral: Hospital Capability Lack of Specialist Financial Constraints


Others___________________________________________________________________

Referral by:
_______________________________________
Printed Name and Signature
NDP/RHMM/BHW
License #:

Note: Referring facility to retain a duplicate copy of clinical Referral Form for record purposes
And data profiling: Please attach laboratory work-ups.
--------------------------------------------------------------------------------------------------

RETURN REFERRAL SLIP


(To be filled up by recipient hospital upon discharge: Fax/Mail or referring unit)
Date: _______________________________________________________ Time: ____________________________________________________
Name: _____________________________________________________________________ Sex: ______________ Age: __________________
(Surname) (First Name) (Middle Name)
Address: _______________________________________________________________________________________________________________
Diagnosis/Impression: __________________________________________________________________________________________________
________________________________________________________________________________________________________________________
Recommendation/Instructions: _________________________________________________________________________________________
________________________________________________________________________________________________________________________

______________________________________
Printed Name and Signature
Hospital:
Address & Contact #:

Note: Return referral Slip should be sent back to the referring facility after entering details in the Referral Logbook of the recipient facility.

---------------------------------------------------------------------------------------------------

ACKNOWLEDGEMENT RECEIPT (to be given to the Driver)


This is to acknowledge ___________________________________________________ (name of patient) receipt at
_____________________________________________ (name of recipient hospital) this _________________________ (date).

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