SURIGAO DOCTORS’ HOSPITAL, INC.

Sitio Kinabutan, Brgy. Rizal, Surigao City

“A Hospital with a Heart”
REFERRAL SLIP
TO:
FROM:
WARD/ROOM/BED NO.: CASE NO.:
NAME Last Name First Name Middle Name AGE: SEX:

Brief summary of HX and PE:

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Diagnosis:
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We are referring for:

 1. Opinion
 2. Pre-Op Clearance
 3. Opinion and c0-management
 4. Follow – up
 5. Others:
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Attached is the Clinical Abstract.

Thank you very much.
 This is an EMERGENCY referral.
 This is NOT AN EMERGENCY referral.

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 Signature over printed name

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Position
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Department
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Date