‫الرقم‬

Health Care No
‫الصحي‬

Name ‫االسم‬
Age ‫العمر‬ Sex ‫ذكر‬ ‫الجنس‬

Eradh Complex of Mental Health Nationality ‫سعودي‬ ‫الجنسية‬

Medical Referral Center Consultant In- ‫االستشاري‬
Department of Eligibility for Treatment charge ‫المسئول‬
and Medical Coordination Center of
Internal
.Dept ‫القسم‬ Unit Social ‫الوحدة‬
Medicine Fraternization
REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬
TO DR DEPT
DESIGNATION HOSPITAL / PHC
FROM DR DEPT Center of Social Fraternization
DESIGNATION HOSPITAL / PHC ERADAH COMPLEX IN Riyadh

DIAGNOSIS

PATIENT'S CONDITION : Stable  Critical Conscious  Unconscious

REASON FOR REFERRAL :  Consultion  Admission Treatment
… Further Investigation Other :
TRANSPORTATION : Ambulance  Helicopter Air Other:…patient herself…….
ESCORT : None Doctor  Nure Relative Other:…………..
DOCUMENTS SENT : Med.Report Lab.Result X_ray  Other:…………..
Dr.'s Name
Date : 27/09/2021
Mobile #
Print time :<CURRENT_DATE> <CURRENT_TIME> By User ID :<USER_CREATED> DOCUMENT_ID # <DOCUMENT_ID>