TWO – WAY REFERRAL FORM

Type of referral: ( ) Priority or Emergency ( ) Non – Emergency

Reasons of Referral:
Address: R. Kangleon St. Maasin City, Southern Leyte

Referred To: Date/Time:

PATIENT’S Category: Health Insurance ( specify ) ( ) Charity ( ) Pay
Referring Hospital/Clinic: CM Maternity Clinic

Name of Patient:
Age: Sex: Civil Status: Occupation: Religion:
Address:
Responsible Person: Relation: Tel/Cell#:
Admitting Impression:

Vital Signs: BP HR/PR RR Temp. Wt. Blood Type

Allergies: Other Vital Data:

Abstract/History ( may attach a separate sheet if necessary)

Diagnostic Procedure Done/ Treatment Given (Pls. specify the date, dose, time last given); (may
attach a separate sheet if necessary)
Referred by:

Signature over Printed Name Designation Tel/Cell Number

RETURN SLIP/ DISCHARGE SLIP ( for pick – up by the hospital’s designated person)
DATE:
Referring Hospital: CM Maternity Clinic

To Hospital/ILHZ/RHU/Clinic of Origin:
Address: Maasin City, Southern Leyte

From: Date Admitted: Date Discharge:

Name of Patient:
Age: Sex: Civil Status: Occupation: Religion:
Address:
Final Diagnosis:

Action/s Taken (may attach a separate sheet if necessary)

Recommendation (may attach a separate sheet if necessary)

Signature over Printed Name of Attending Physician Designation Tel/Cell Number

ACKNOWLEDGEMENT RECEIPT (for immediate return to hospital/ clinic of origin by

Referring Hospital: CM Maternity Clinic

the accompanying hospital/ clinic personnel)

Address: Maasin City, Southern Leyte

DATE/TIME:

Name of Patient:
Address: Age: Sex: Civil Status:
Status/Condition upon Receipt at ER:
Action Taken: ( ) Admitted ( ) Referred to other facility ( ) Treated/manages as OPD
Attachment Received: ( ) X- ray results/ plates ( ) Laboratory results ( ) others

Receiving Hospital Contact Person Tel/Cell Number