REFERRAL

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HOSPITAL NETWORKING REFERRAL FORM

TO________________________________ _____________________
Hospital Case No.
Pediatrics Surgery/Orhopedic Medicine Ob-Gyne Other__________________

Name of Patient:___________________________________________________________________
Address:__________________________________________________________________________
Birthdate:___________________ Age:__________ Sex:__________ Civil Status________________

Chief of Complaint :

Clinical History

Vital Sign: BP:_____________ Temp:________ CR:_______ RR:______ O2 Sat:________GCS:_______ Wt(kg):________

Other Significant Physical Findings:

Treatment: Time Last Treatment: Time Last


Dose Dose
Given: Given:
_________________________________________ _______________ _________________________ ________________
_________________________________________ _______________ _________________________ ________________
_________________________________________ _______________ _________________________ ________________
_________________________________________ _______________ _________________________ ________________
_________________________________________ _______________ _________________________ ________________
_________________________________________ _______________ _________________________ ________________

Impression:
_____________________________________________________________________________________________________________________________________________
______________________________________________________________________________________________________________________________________

Mode of Conduction: Reason for Referral


Conducted via Private Patient/ Relative’s request
Conducted via Ambulance For Diagnostic Procedure
Conducted without Escort For further evaluation and management
Others_________________ Others_______________

___________________________ __________________________
Conforme Referring Physician
Note: Copy of Ancillary Procedures attached at the back

HOSPITAL NETWORKING REFERRAL REPLY

NAME OF HOSPITAL:_____________________________ Hospital Case No.__________


Patient:______________________________________________ Date: ____________________
Address:_______________________________________________
Age:_________________ Sex: ___________ Civil Status: _____________

Impression:_______________________________________________ __________________________
Attending Physician

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