Mao-Aweys International Hospital

Mao-Aweys Plaza, 10th Street Second Avenue, Eastleigh, Nairobi

Tel: 0796 529 181 - 0796 529 182
P.O Box 2732 00610

NAME: _______________________________________________________ ID NO: ________________________

MEMBER NO: _______________________ RELATIONSHIP TO MEMBER: ____________________
REG NO: ________________________ AGE: ______________ DATE: ________________________________
REFERRAL LETTER
MEDICAL HISTORY:

INVESTIGATIONS DONE:

DIAGNOSIS:

TREATMENT GIVEN AND RECOMMENDATION:

REASON FOR REFERRAL:

DOCTOR’S NAME: _________________________________________________________

DOCTOR’S SIGNATURE: __________________________________________________