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Referral Form

The document is an inter-health facility referral slip used by the Municipal Health Office in Buguey, Cagayan, Philippines. It includes sections for patient information, clinical history, physical examination, impressions, actions taken, and reasons for referral. Additionally, there is a return slip for acknowledgment of patient receipt by the receiving facility.

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Josette Mae Atanacio
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102 views2 pages

Referral Form

The document is an inter-health facility referral slip used by the Municipal Health Office in Buguey, Cagayan, Philippines. It includes sections for patient information, clinical history, physical examination, impressions, actions taken, and reasons for referral. Additionally, there is a return slip for acknowledgment of patient receipt by the receiving facility.

Uploaded by

Josette Mae Atanacio
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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REPUBLIC OF THE PHILIPPINES

PROVINCE OF CAGAYAN
MUNICIPALITY OF BUGUEY
Municipal Health Office
Tel. No.: ______________
INTER-HEALTH FACILITY REFERRAL SLIP
Referred to: __________________ Date and Time Referred:
______________
Name of Facility
__________________
Complete Address
__________________
Contact Number
PATIENT NAME: ____________ _____________ _______________ Age/Sex ____ CS ___ Blood
Type____
SURNAME GIVEN NAME MIDDLE NAME

COMPLETE ADDRESS: _________________________________________


CLINICAL HISTORY: __________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________
PERTINENT PHYSICAL EXAM
BP: ________ RR: _______ PR: _______ TEMP: _______ WT: ________
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________
IMPRESSION:
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________
ACTION/S UNDERTAKEN (medication, laboratory/diagnostic procedure, etc.):
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________
REASON FOR REFARRAL:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
____________

Referred by: _________________________


Signature over Printed Name/Position
Contact No.: ____________________
--- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- --- ---
RETURN SLIP
Slip to be given to accompanying staff/driver

This is to acknowledge that ______________________________ accompanied by _____________________


(Name of Patient) (Name of Staff/Position)

was received at ________________________ on ______________ status of patient upon arrival ____________

Received by: __________________________


(Signature over printed name)
Contact No.: _______________

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