Annex 5.

Referral and Service Slip

REFERRAL SLIP Date:_______________________________

Name of Clients: __________________________________________________

Address of Clients: __________________________________________________

Instruction: PLEASE CHECK APPROPRIATE OPTIONS BELOW

1. Expressing intention to use with the method below:
NFP Method Check Artificial Method Check Permanent Method Check
SDM Pills Ligation
LAM IUD Vasectomy
CMM Injectable
STM Condom
Implant

2. Wants FP but undecided on what method to use (___)

3. Undecided, need further counseling (___)

4. Use of traditional method (please specify method use) ___________________________

NOTE: This portion is for COMMUNITY VOLUNTEER
Client is referred to:

Name of Health Service Facility(BHS, RHU, Hospital)________________________________

Address of Health Service Facility:______________________________________________

Community Volunteer (BSPO/BHW,BNS,etc.) who referred the client

____________________________________________________
Name and Signature