ANNEX D

INTER-AGENCY REFERRAL FORM

10/19/2022
MC-DOPMC-DSWD
MATI CITY, DAVAO ORIENTAL

PATIENT’S DATA
DALAGAN, ANGELITA E. 68 WIDOWER
Name of Patient: Age: ______ Status:
________ DAVAO ORIENTAL
Address: _____________________________________________________________
CLINICAL DATA:
LUMBAR PAIN
______________________________________________________________________
NUMBNESS OF UPPER EXTRIMETIES
______________________________________________________________________
______________________________________________________________________
CLINICAL IMPRESSION:
WITH PRESCRIPTION
______________________________________________________________________
____________________________________________________________________

MEDICAL SOCIAL WORKER’S ASSESSMENT:

The patient is a senior citizen and relying to her cash assistance from her Senior citizen
and food/financial support of her children. The support is not enough to suffice her
needs due to their monthly bills and has no other means of income. The family is
classified as D-Indigent. She is desperately seeking for financial assistance for her
medicines. The medicines that prescribe to her is unavailable to the DOPMC-
PHARMACY. Hence, the Medical Social Worker refers the client to your good office in
order to meet her needs.

Prepared by: Noted by:

GLADYS B. IBAÑES, RSW METCHIE GAY S. LINAZA, RSW

Medical Social Worker Chief of Medical Social Work Department