Page 1 of 1 Gala yh & QatarEneray QP Center for Health and Wellness, Doha, State of Qatar Phone: +974 4013 5555, Fax: +974 4013 9433, REFERRAL LETTER Medical File No: 00705607 HMG Gard No: Name: Kenzio athalla Gazza Claim Form No: 0004893692 Date of Birth 07/04/2016 Sox Male Staff No: 03763503 ‘Sequence No REFERRAL DETAILS _] Referral Date: 27/02/2022 Referred To ‘Speech Therapist teen of Elective Valid Unt: ‘Three Months JREASON FOR REFERRAL. ‘Subjective : speech delay and articulation problem Objective : normal development Assessment : speech delay Plan: speech therapy twice per week for 3 months [SPECIFIC REASON FOR REFERRAL Diagnosis review *RINCIPAL DIAGNOSIS Delayed;articulation Medical practitioner declaration: | dectare that | am the patients medical practitioner, and that the particulars given are to the best of my knowledge true ‘and correct y Name:Dr. Talseer Abdel Raouf Anmed BRR RR EDDA READE DEDEDE Dee SS PLEASE GUT THIS PORTION AND RETURN TO THE PATIENT AFTER FILLING (00705807 Kenzio athalla Gaza 07/08/2016 Male CONSULTING FEEDBACK eee ee ees [NAME OF CARE PROVIDER, [SIGNATURE AND STAMP [DATEISH aed Bball y aul bd 5S yo Qatar Institute for Speech and Hearing w.. ATTENDANCE SHEET 20/02/22 Register No: QS-4092 ‘Name : Kenzio Athallah Gazza ID: 31636000163 ‘Amount SL# Date Services Therapist Received 1_| 5/2/2022 Speech Therapy Ms. Afnida Ismail 325.00 2__| 12/2/2022 Speech Therapy Ms. Afnida Ismail 325.00 3__| 19/02/22 Speech Therapy 325.00 4 | 20/02/22 Speech Therapy Ms. Afnida Ismail 325.00 pmnoae ONE THOUSAND THREE HUNDRED QATAR RIYALS ONLY 1,300.00 in words QATAR INSTITUTE FOR SPEECH AND HEARING Tel: 4974 44122742, Fax: +974 44122704, C.R. 47854 , Doha - Qatar stab anya tvnet cage eA ITIVE aS AVE LEVTIVEY ald218122, 1:07 PM ishapp Qatar Institute for Speech and Hearing WLL ‘Al Jaseera Al Arabiya Street Madinat Khalifa (S) Doha Qatar PO Box : $498 Mob: 74402742 ‘TEL: 44122742/44873909 FAX: 44122704 EMAIL: support@qish info, WEB: qish.info CRE 47854 SCH Lict: 1078 Register# (QS-004092 Date 2022-02-05 Name ‘Kenzio Athalla Gazza Receipt 30773 ID 31636000153 Operator 1D admini SL# [Particulars (Consultant [Nos. [Ratel[Total] 1 [Speech Language Pathology - [Afnida ia [325 1300] [English yo ee) Re * £ " * ESV [TOTAL Si *#* Payment for ADV 4*325 for 5S For Qatar Institute of Speech and Hearing: (Staff ID: admin!) disp tidi DONA BANK IN’ Te ‘SPEECH&HEARING 0 mn: a 3 SALE MASTER (1) EXP semeex 5521 13%« xx G019 Pan SEO WO GL a OCA PRAT Bea ON Ss AMOUNT OR 1300.08 APPROVAL: W16I 44