Health Care No 3142 ‫الرقم الصحي‬

Name Abdul Rahman Al Qumeez ‫االسم‬

Age 64 ‫العمر‬ Sex male ‫الجنس‬
Nationality saudi ‫الجنسية‬
‫المملكة العربية السعودية‬ ‫االستشاري‬
Consultant In-charge Eradh Complex of Mental Health ‫المسئول‬
‫وزارة الصحة‬

‫التجمع الصحي الثالث‬

‫مجمع ارادة والصحة النفسية بالرياض‬ .Dept INTERNAL ‫القسم‬ Unit ‫الوحدة‬

‫قسم أهلية العالج والتنسيق الطبي‬

REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬

TO DR OPHTHALMOLOGIST DEPT OPHTHALMOLOGY
OPHTHALMOLOGY Hospital in
DESIGNATION HOSPITAL / PHC
Riyadh
FROM DR AL-Ekhaa Center DEPT INTERNAL
DESIGNATION HOSPITAL / PHC Eradh Complex of Mental Health

Known patient with past history of chronic schizophrenia PUT on : (1- risperidone2 mg HS ).

& DM, HTN , RENAL IMPAIRMENT, IHD PUT ON : -ATORVASTATIN 20 MG OD , -ASA81 MG OD,AMODIPINE 5 MG OD ,
ISOSORBID 20 MG OD , MRTFORMIN 500 MG TID , ATENOLOL 25 MG OD , MIXTARD INSULIN 20-10

-the patient complains of loss vision and now his condition has increased , he needs evaluation in ophthalmo clinic

And treatment …

with full thanks.

PATIENT'S CONDITION :  Critical Conscious  Unconscious

REASON FOR REFERRAL :  CONSULTATION &TREATMENT Further Investigation
Other : ADMISSION

DOCUMENTS SENT :  Med.Report Lab.Result X_ray  Other:…………..

Dr.'s Name MAZEN HAJ AHMAD
Mobile # 0595603653