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    Referral Form

    Uploaded by

    RANDY BAOGBOG
    This health referral form from the Municipality of Candoni Municipal Health Office in Negros Occidental, Philippines contains information about a patient referral. It includes the patient's name, age, sex, address and other identifying details. The form notes the patient's chief complaint, physical examination findings, impression or diagnosis, and the treatment already provided. It indicates the reason for referral, such as further evaluation or management, and specifies the facility to which the patient is being referred. The return slip section is for the receiving facility to document its diagnosis, actions taken, and recommendations.

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Referral Form

    Uploaded by

    RANDY BAOGBOG
    329 views2 pages
    This health referral form from the Municipality of Candoni Municipal Health Office in Negros Occidental, Philippines contains information about a patient referral. It includes the patient's name, age, sex, address and other identifying details. The form notes the patient's chief complaint, physical examination findings, impression or diagnosis, and the treatment already provided. It indicates the reason for referral, such as further evaluation or management, and specifies the facility to which the patient is being referred. The return slip section is for the receiving facility to document its diagnosis, actions taken, and recommendations.

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    © © All Rights Reserved

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    This health referral form from the Municipality of Candoni Municipal Health Office in Negros Occidental, Philippines contains information about a patient referral. It includes the patient's name, age, sex, address and other identifying details. The form notes the patient's chief complaint, physical examination findings, impression or diagnosis, and the treatment already provided. It indicates the reason for referral, such as further evaluation or management, and specifies the facility to which the patient is being referred. The return slip section is for the receiving facility to document its diagnosis, actions taken, and recommendations.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    329 views2 pages

    Referral Form

    Uploaded by

    RANDY BAOGBOG
    This health referral form from the Municipality of Candoni Municipal Health Office in Negros Occidental, Philippines contains information about a patient referral. It includes the patient's name, age, sex, address and other identifying details. The form notes the patient's chief complaint, physical examination findings, impression or diagnosis, and the treatment already provided. It indicates the reason for referral, such as further evaluation or management, and specifies the facility to which the patient is being referred. The return slip section is for the receiving facility to document its diagnosis, actions taken, and recommendations.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    Republic of the Philippines

    Province of Negros Occidental


    MUNICIPALITY OF CANDONI
    Municipal Health Office

    Health Referral Form


    Priority/Emergency Referral Outpatient ReferralHospital Case No.:________________________________
    Referred to: ______________________________________ Referral From: _________________________ Date: ___/____/______ Time: ________
    Name of Patient: ________________________________________________________ Sex: __________ Age: _________ Civil Status:
    ___________
    (Surname) (Given name) (Middle name)
    Parent/Guardian (in case of minor) ______________________________________Address:______________________________________________
    (Barangay) (Municipality/City) (Province)
    Religion: _________________ Occupation: _________________ PHIC ID No. ____________________________ Non-PHIC
    Chief Complaint Brief History:
    ________________________________________________________________________________________________________________________
    ________________________________________________________________________________________________________________________
    ________________________________________________________________________
    Patient Physical Examination Findings: BP: ____/_____mmHg PR/HR: ____bpm RR: ____cpm Temp.: ______°C Wt: ____kg/s
    Impression/Diagnosis: _____________________________________________________________________________________________________
    Action Taken/Treatment Given: _____________________________________________________________________________________________
    ________________________________________________________________________________________________________________________
    Reason for Referral:
    Further Evaluation & Management Per Patient Request No Doctor Available
    For Work-up Medico-Legal Others __________________________________

    Referred by: _____________________________________ ______________________________


    (Printed Name & Signature) (Designation)
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    RETURN SLIP
    Date: ___/____/______ Time: ________ To: ___________________________________________________________________________________
    Name of Patient: ____________________________________________________________________________ Sex: __________ Age: __________
    (Surname) (Given name) (Middle name)
    Parent/Guardian (in case of minor) ______________________________Address: ______________________________________________________
    (Barangay) (Municipality/City) (Province)
    Diagnosis-Impression: _____________________________________________________________________________________________________
    Action Taken: ____________________________________________________________________________________________________________
    Recommendation/Instruction: _______________________________________________________________________________________________

    ________________________________ ___________________________
    (Printed Name & Signature) (Designation)

    Republic of the Philippines


    Province of Negros Occidental
    MUNICIPALITY OF CANDONI
    Municipal Health Office

    Health Referral Form


    Priority/Emergency Referral Outpatient ReferralHospital Case No.:________________________________
    Referred to: ______________________________________ Referral From: _________________________ Date: ___/____/______ Time: ________
    Name of Patient: ________________________________________________________ Sex: __________ Age: _________ Civil Status:
    ___________
    (Surname) (Given name) (Middle name)
    Parent/Guardian (in case of minor) ______________________________________Address:______________________________________________
    (Barangay) (Municipality/City) (Province)
    Religion: _________________ Occupation: _________________ PHIC ID No. ____________________________ Non-PHIC
    Chief Complaint Brief History:
    ________________________________________________________________________________________________________________________
    ________________________________________________________________________________________________________________________
    ________________________________________________________________________
    Patient Physical Examination Findings: BP: ____/_____mmHg PR/HR: ____bpm RR: ____cpm Temp.: ______°C Wt: ____kg/s
    Impression/Diagnosis: _____________________________________________________________________________________________________
    Action Taken/Treatment Given: _____________________________________________________________________________________________
    ________________________________________________________________________________________________________________________
    Reason for Referral:
    Further Evaluation & Management Per Patient Request No Doctor Available
    For Work-up Medico-Legal Others __________________________________

    Referred by: _____________________________________ ______________________________


    (Printed Name & Signature) (Designation)
    _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _
    RETURN SLIP
    Date: ___/____/______ Time: ________ To: ___________________________________________________________________________________
    Name of Patient: ____________________________________________________________________________ Sex: __________ Age: __________
    (Surname) (Given name) (Middle name)
    Parent/Guardian (in case of minor) ______________________________Address: ______________________________________________________
    (Barangay) (Municipality/City) (Province)
    Diagnosis-Impression: _____________________________________________________________________________________________________
    Action Taken: ____________________________________________________________________________________________________________
    Recommendation/Instruction: _______________________________________________________________________________________________
    ________________________________ ___________________________
    (Printed Name & Signature) (Designation)

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