‫الرقم‬

Health Care No 792 ‫الصحي‬

Name ‫حسين عبد الرحمن الحسين‬ ‫االسم‬

Age 48 ‫العمر‬ Sex ‫ذكر‬ ‫الجنس‬

Eradh Complex of Mental Health Nationality ‫سعودي‬ ‫الجنسية‬

Medical Referral Center Consultant In- ‫االستشاري‬
Department of Eligibility for Treatment DR .FAHAD AL SAKAL
charge ‫المسئول‬
and Medical Coordination Internal Center of Social
.Dept ‫القسم‬ Unit ‫الوحدة‬
Medicine Fraternization

REFERRAL FORM ‫نـمــوذج تـحـــــويـــــــل‬

TO DR DOCTOR ON DUTY DEPT PERMANENT CARE
DESIGNATION HOSPITAL / PHC
FROM DR MAZEN HAJ AHMED DEPT Center of Social Fraternization
DESIGNATION RESIDENT DOCTOR HOSPITAL / PHC ERADAH COMPLEX IN Riyadh
:Clinical history

: Known patient with past history of chronic schizophrenia on

(1- HALOPERIDOL 5 MG BID , 2- RISPERIDONE 2 MG AM & 4 MG PM ,3- ESCITALOPRAM 10 MG OD )

Now Patient currently bed ridden , , mute, incontinent for urine and stool in a such situation the patient is -
greatly liable for development of a bed sores and infections , patient completely dependent on others and need
.continuous nursing care, medical follow up

Therefore, the patient needs a very special nursing care, and we suggest transferring the patient to a specialized -
..hospital for his condition

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
MAZEN HAJ AHMED Date : 18/05/2021
Mobile # 0595603653

Print time :<CURRENT_DATE> <CURRENT_TIME> By User ID :<USER_CREATED> DOCUMENT_ID # <DOCUMENT_ID>