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Referral Form for Ophthalmology Consultation

This document is a referral form for 64-year-old Saudi male Abdul Rahman Al Qumeez from the Eradh Complex of Mental Health to an ophthalmologist. Mr. Al Qumeez has a history of chronic schizophrenia and other medical conditions such as diabetes, hypertension, and renal impairment. He has been experiencing loss of vision and needs an evaluation and treatment from an ophthalmologist. The referral is for a consultation and treatment for his worsening vision condition. Relevant medical records and lab results are being sent with the patient.

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115 views1 page

Referral Form for Ophthalmology Consultation

This document is a referral form for 64-year-old Saudi male Abdul Rahman Al Qumeez from the Eradh Complex of Mental Health to an ophthalmologist. Mr. Al Qumeez has a history of chronic schizophrenia and other medical conditions such as diabetes, hypertension, and renal impairment. He has been experiencing loss of vision and needs an evaluation and treatment from an ophthalmologist. The referral is for a consultation and treatment for his worsening vision condition. Relevant medical records and lab results are being sent with the patient.

Uploaded by

raad_alghamdi_1
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Health Care No 3142 ‫الرقم الصحي‬

Name Abdul Rahman Al Qumeez ‫االسم‬


Age 64 ‫العمر‬ Sex male ‫الجنس‬
Nationality saudi ‫الجنسية‬
‫المملكة العربية السعودية‬ ‫االستشاري‬
Consultant In-charge Eradh Complex of Mental Health ‫المسئول‬
‫وزارة الصحة‬

‫التجمع الصحي الثالث‬

‫مجمع ارادة والصحة النفسية بالرياض‬ .Dept INTERNAL ‫القسم‬ Unit ‫الوحدة‬

‫قسم أهلية العالج والتنسيق الطبي‬

REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬


TO DR OPHTHALMOLOGIST DEPT OPHTHALMOLOGY
OPHTHALMOLOGY Hospital in
DESIGNATION HOSPITAL / PHC
Riyadh
FROM DR AL-Ekhaa Center DEPT INTERNAL
DESIGNATION HOSPITAL / PHC Eradh Complex of Mental Health

Known patient with past history of chronic schizophrenia PUT on : (1- risperidone2 mg HS ).

& DM, HTN , RENAL IMPAIRMENT, IHD PUT ON : -ATORVASTATIN 20 MG OD , -ASA81 MG OD,AMODIPINE 5 MG OD ,
ISOSORBID 20 MG OD , MRTFORMIN 500 MG TID , ATENOLOL 25 MG OD , MIXTARD INSULIN 20-10

-the patient complains of loss vision and now his condition has increased , he needs evaluation in ophthalmo clinic

And treatment …

with full thanks.

PATIENT'S CONDITION :  Critical Conscious  Unconscious


REASON FOR REFERRAL :  CONSULTATION &TREATMENT Further Investigation
Other : ADMISSION

DOCUMENTS SENT :  [Link] [Link] X_ray  Other:…………..


Dr.'s Name MAZEN HAJ AHMAD
Mobile # 0595603653

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