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  • ED Referral Slip Form

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    Jm unite
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    Original Title

    ED RETURN SLIP

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
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    49 views2 pages

    ED Referral Slip Form

    Uploaded by

    Jm unite

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    Republic of the Philippines

    Department of Health
    Regional Office No. 02
    Cagayan Valley Medical Center
    EMERGENCY DEPARTMENT

    RETURN/FEEDBACK SLIP

    Referring Facility Copy

    Date: __________________
    Time: _________________
    Status of Patient upon arrival: __________________________
    Initial Impression: _________________________________________________________________
    ________________________________________________________________________________

    Receiving Physician: ______________________________________________________________


    Print Name & Signature

    Feedback:
    ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________

    Acknowledged by: ________________________________________________________________

    ------------------------------------------------------------------------------------------------------------------------

    RETURN/FEEDBACK SLIP

    CVMC ED Copy

    Date: __________________
    Time: __________________
    Status of Patient upon arrival: __________________________
    Initial Impression: ________________________________________________________________
    ________________________________________________________________________________

    Receiving Physician: ______________________________________________________________


    Print Name & Signature
    Feedback:
    ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________
    ________________________________________________________________________________

    #02 Dalan na Pagayaya, Carig Sur, Tuguegarao City, Cagayan


    Tel. No. (078) 302-0000 local 133
    Email add.:cvmced@yahoo.com

    Philhealth Accredited

    Certificate Number: SCP000187Q


    Republic of the Philippines
    Department of Health
    Regional Office No. 02
    Cagayan Valley Medical Center
    EMERGENCY DEPARTMENT

    #02 Dalan na Pagayaya, Carig Sur, Tuguegarao City, Cagayan


    Tel. No. (078) 302-0000 local 133
    Email add.:cvmced@yahoo.com

    Philhealth Accredited

    Certificate Number: SCP000187Q

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