Template of referral letter (sample 1)

................................Department,
Penang Hospital, Residency Road,
10990 Penang.
___________________________________________________________________________________________________________
……………………………………………….,
………………………………. Department,
Penang Hospital, Residency Road
10990 Penang Date:
Dear Dr.…….,
Re Mr. ABC Age: 45year old (I/C 65010101222)
I would be grateful if you could kindly see and advice regarding management of this right handed
teacher whom I first saw on 20 Nov 2020.

History
Mr. ABC was admitted on 20 Nov 2020 with a first ever unprovoked generalized tonic clonic
seizure. He has a past history of hypertension for 5 years on perindopril 4mg daily. There is no
family history of significance.

Allergies
No known allergy.

Physical examination
Clinical examination was unremarkable.

Relevant Investigation Results:

Baseline blood investigations, cranial MRI and EEG were normal.

Provisional Diagnosis / Sole problem

Late onset first ever unprovoked generalised seizure.

Management
He has not been started on any medication yet.

His family and he have been told that he has had a fit for which no cause has yet been found, and
that he is being referred to a neurologist for expert opinion on further management.

Thank you for reviewing Mr. ABC.

Sincerely,
(DR…………...)
House Officer
H/P: 016-8973316