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TWO-WAY REFERRAL FORM

MacArthur, Leyte

Type of Referral: Priority or Emergency Non-Emergency

Reasons of Referral:
Referring Hospital: Rural Health Unit of Mc ARTHUR (BHS:

Referred To: Date/Time:

Patients Category: Health Insurance (specify) Charity Pay

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)
Address:

Referred by:

Signature over Printed Name Designation Tel/Cell Number

RETURN SLIP/ DISCHARGE SLIP (for pick-up by the hospitals designated person)
MacArthur, Leyte

DATE
Referring Hospital/ Clinic: Rural Mc ARTHUR

To Hospital/ ILHZ/ RHU/ Clinic of Origin:

From Date Admitted: Date Discharged:

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)

Address:

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

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

MacArthur, Leyte

the accompanying hospital/ clinic personnel)

DATE/TIME
Referring Hospital: Rural Mc ARTHUR

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

Receiving Hospital Contact Person Tel/Cell Number

Address: