‫الرقم‬

Health Care No 28978 ‫الصحي‬

Name ‫عبد الرحمن زايد العتيبي‬ ‫االسم‬

Age 60 ‫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 Urology OPD DEPT Urology OPD
DESIGNATION HOSPITAL / PHC
FROM DR MAZEN HAJ AHMAD DEPT Center of Social Fraternization
DESIGNATION RISEDENT HOSPITAL / PHC ERADAH COMPLEX IN Riyadh
Clinical history: Known patient with past history of chronic schizophrenia on : olanzapine 10 mg bid

And he put on : - multivitamin od , multienzyme od ,calcium 600 mg bid , propranolol 10 mg od , aspirin 81 mg od

The patient complained of urinary retention and inability to urinate, he was transferred to the emergency

department at King Salman Hospital on 2/4/2021, where a urinary catheter was placed for the patient for a

period of 15 days and an appointment was recommended in the OPD clinics of the hospital..

FOR ASSESSMENT

DIAGNOSIS
Provisional 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:…………..
MAZEN HAJ AHMAD
Dr.'s Name
Date : 14/04/2021
Mobile # 0595603653

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