Republic of the Philippines

Province of Iloilo
Municipality of Concepcion

CONCEPCION RURAL HEALTH UNIT

Animal Bite Referral Form

Date: _________________

To: ________________________________________

I respectfully referring ________________________________________, _________, ________

(Name of Patient) (Age) (Sex)

Address: ________________________________________________
Date of Exposure: ________________________________________________
Nature of Bite: ________________________________________________
Site of Bite: ________________________________________________
Category of Bite: ________________________________________________
Action Taken: ________________________________________________

Action Desired: ________________________________________________________________________

________________________________________________________________________
________________________________________________________________________

Referred by: ________________________________

RETURN SLIP
To: ______________________________________ From: ____________________________________
______________________________________ ____________________________________

Name of Patient: _______________________________________________________________________

Address: _______________________________________________________________________
Action Taken: _______________________________________________________________________
Remarks: _______________________________________________________________________

____________________________
(Name/Position)