GOVT MOHAN KUMARAMANGALAM MEDICAL COLLEGE HOSPITAL, SALEM

DEPARTMENT OF PAEDIATRICS
PATIENT REFERRAL FORM
Name: __________________ Age: ______________ Sex: ____________________

IP No.: _________________ Date of Admission: ______________

Address of the Patient: __________________________________________________________
_____________________________________________________________________________
Parent’s Mobile No: ___________________________________________________
Provisional Diagnosis: ___________________________________________________________

Treatment Given: _______________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________

_____________________________________________________________________________
_____________________________________________________________________________
Reason for Referral: ___________________________________________________________
Referred to: ___________________________ Date: ____________ Time: _____________
Name & Designation of Referring Doctor: ___________________

Parent’s Signature Doctor Signature

Telephonic Message that conveyed to Referral Center along with time:
______________________________________________________________________________
Name of the Ambulance Point:
______________________________________________________________________________

Mobile No: ___________________________ Vehicle No:

_______________________________

Name & Designation of Receiving Officer