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MINISTRY OF HEALTH
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HOTA BANI TAMIM GENERAL HOSPITAL
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REFERRAL FORM
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NAME OF THE PATIENT: ZAID ABDULLAH RASHID ALMOSA
AGE:40 YEARS OLD SEX: MALE NATIONALITY: SAUDI MRD#: 703
CONSULTANT-IN-CHARGE:DR. AHMED ELNAGAR
DEPARTMENT: ORTHO UNIT: OPD
TO DR:RADIOLOGIST DEPARTMENT: RADIOLOGY
DESIGNATION: CONSULTANT HOSPITAUPHC:
FROM DR.AHMED ELNAGAR DEPT: ORTHO
DESIGNATION: CONSULTANT HOSP/PHC: HBTGH

CLINICAL HISTORY: 40 years old male Saudi patient suffer from swelling in the volar
aspect of Right distal forearm.

PHYSICAL DGMINATIoN: Firm swelling over volar aspect of Right distal forearm.

INVESTIGATION: U/S reported soft tissue mass Q? schwannoma

PROBLEMS/DIAGNOSIS:Firm swelling Q? aneurysm or soft tissue lesion.

TREATMENT/ PROCEDURE DONE SO FAR:

PATIENT CONDITION: Stable Critical Conscious Unconscious

REASON FOR REFERRAL: We refer for MRI RIGHT DISTAL FOREARM.

r/ Consultation Admission Treatment

{ Further investigation others:

-/-)

ELNAGAR DR: ABDULNASSER SKHEITA

ORTHO CONSULTANT MEDICAL DIRECTOR
DATE OA03t2022 DATE02l03t2022
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Respiratory Triage Checklist

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Narnai lo, rt A,l B Laehtd g,U Hospital:
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Rlsks for Acitto Respiratory lllnessas Score

A. Exposure Risks AII patients

A contact wittJ.confmtedcasa or-CovttLlg or MERS-CoVin the last 14 days

prior.F surrBosrs onseb.

Or

Aa e)eart€ to camol or earnr{b producB in thr la3t 14 d8ys prior to symptorns

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Or

Liv6d In or wo.ked ln facility larown to e experiencing

in thg last 14 days pdor to slmptoms.
J outbreak o, COVID-19
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B. Clinical Slgns and Symptoms. Pediatric Adult
1. Fever or recent history of fever. I /4 o /4
2. Cough (new or woGening), /4
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3, Shortness of brBath (new or yrorsenlng). /4 o /4

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4. Headache, sore thtoat, or rhinonhea. /1 o /1

5. Nausea, vomhing, and/or dianhea. /1 /1
6. Chronic Renal Failure, CAD/ Heart Failure, I patient o/1
Total Score 0 0
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A score >= 4, ask the patient to perform hand hygiene , wear a surgical mask.
Follow isolation precaution and then contact The Op'eration Department for further instruction.
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SURGICAL AND MEDICAL INTERVENTIONAL PROCEDURE ;trihi:t .-rtrt1.:{te,a:tdt rtF!

l,theundersig
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On my behalf :013 aJlll ltr 9iU\,,rij O,r,iltallL
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Here by authorize Dr.
and his assistants to perform the following Udihill !lr+.IU,AaslJ-:tl;tl ^-ll tlpLr arxL.ag
Surgical Operation lnterventional
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The physician has fully explained to me my condition, t.:lJigg ,r.F;^ll ;lt.tll a.t5 d.ll ilrltillg .4fihill rlp ltl
the reason5 forthe Medical lnterventional Procedures/ ;r^i'^rlAri^rl9 jjlict.^oJlg a+r&ll :jlgall
surgery ha5 also informed me of the expected
benefits & complications, possible discomforts & a,-ril ld .-,rh.i9 VrJ tlp{l/,i+ladl al.i e, riS
risks that may arises as well as possible alternatives . agaei k+ d.lb{l .-ra-r-g
'ilt ,rjll
to the proposed treatment. :;l ^;.^ I arrrrill (:I|Jo.l.r,^ll UtJ . -. -rJir
The procedure has been explained to me as above
and I had the chance to have my questions and/or
quires answered by my physician. t^,;,.4a,iri.,r.oJl ri ."*bll .{+ y" gffi
Main possible complications: a1ff, Ja
Explained to me without any warranty or guarantee
from the hospital's side as to the result or cure.

The treating physician or his asiistants are entitled

to provide additional procedures as reasonable and
necessary in(luding administration of anesthesia and
performance of pathology and radiology or ex€ision :o;ol ./9 9l U,.6'rJaJl &o9li
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of tissue / organ the surgeon deems necessary.
I do also authorize the hospital to keep, use or _:.-.;9ll I / :y:lill
properly dispose any tissue and parts of organs that
are excised during this procedure. rlp{l/ lj!
,aplpJl a$a.cJl cl;rl JJ-6 ,lr-6lll UJr Jrrfhl
Signature of Patient or Guardian . ori!d9 f.6JoJ dj auiq -'^;9 uclall
. ,,'h ll .o-,,-rl
Date / /_ Time:

I have seen this consent before surgery and explained eii : t*igrJl
nature of operation to patienu guardian.
Name of :roLirJl p,ul

Signature: :&n9Jl

Datei I l- Time: :.l-60ll I I :rrrliJl

GDOH-COR-SMrP-353 ISSUED DATE:09/02/2013 10Ft illtlt[ilfllilililtilltililt 5N

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