TWO WAY HEALTH REFERRAL FORM

(Office Name)

Referral Hospital/Clinic : ______________________________________________________

Address : ________________________________________________________________________________________________
Type of referral Non: Priority or emergency
Non - Emergency
Reason for referral: Further evaluation and management
Others : _______________________
Mode of Transportation :_____________________
Referred to: _____________________________________________ Date/ Time: ______________________________________
Name of Patient : ______________________________ Age: ____ Sex: _____ Civil Status : _______________________________
Address : _____________________________ Occupation : ______________ Religion: __________________________________
Responsible Person: ___________________________ Relation : ___________Tel/ Cell No. : _____________________________
Impression : _____________________________________________________________________________________________
Vital Signs: BP : ______ HR/PR ____ RR ____ Temp: _____ Wt: ______ Bld Type: ___________________
Allergies : ______________________________ Other Vital Data : __________________________________________________
Abstract or History ( may attach a separate sheet if necessary ) :

Diagnostic Procedure done / Therapeutic Management ( please specify the date, dose, time last given )
( may attach a separate sheet if necessary )

Referred by:

_______________________________ ____________________________ _________________

Printed Name and Signature Designation Tel./Cell No.

RETURN SLIP/DISCHARGE SLIP

Referring Hospital/Clinic: ______________________________

Address : ________________________________________________________________________________________________
To Hospital/ILHZ/RHU/Clinic of Origin : ________________________________________________________________________
Date/Time Admitted : _____________________________ Date/ Time Discharge: ___________________
Name of patient : ________________________________ Age : _____ Sex : ____ Civil Status : ________
Address : _______________________________ Occupation : ________________ Religion : __________
Final Diagnosis : __________________________________________________________________________________________
________________________________________________________________________________________________________

Action/s Taken:

Recommendation:

__________________________________________ _________________ ________________ _____________

Printed Name and Signature of Attending Physician Designation Date/Time Tel/Cel No.

ACKNOWLEDGEMENT SLIP
( For immediate return to hospital/clinic of origin by accompanying hospital/clinic personnel)

Referring Hospital/Clinic : _______________________________________________

Address : ___________________________________________________________________________
Name : _______________________________________ Age : ___________ Sex : _____________
Status/ Condition Upon Received at ER : _______________________________________________________________________
Date/ Time Received : _______________________________________________________
Attachment Received : ___ X-ray result/plates ___ Laboratory Result ___ others

_____________________________________ __________________________________ _________________________

Referring Hospital Receiving Hospital Date/ Time