(Date of referral)

(Name of the receiving physician)

(Place of work of the receiving physician)

Dear/ Dr. (name of the receiving physician)

I would like to refer (Name of the patient) to your (Place of work of the receiving physician) for
(Reason and type of referral).

(Summarize the clinical setting between the family physician and the patient in your own
words)
And don’t forget to involve (Personal history, Clinical complaint, Present history, Past medical
and surgical history, any drug history or drug sensitivities)

Relevant examination findings

General examination: (findings including vital signs measurements, And any abnormal findings
the physician found concerning the following; (Appearance, built, Upper limb, Lower limb, Head
and neck, Edema, Lymph nodes, Color changes (cyanosis, pallor, jaundice, others))
Local examination: (Abnormal findings concerning the affected system or organ only which
depends on the type of the clinical condition)
Investigations: (Mention the family physician performed investigations during the clinical
setting and their results (either normal or abnormal all is written, There should be also
photocopies of the investigations)
Provisional diagnosis: (The family physician’s suspected diagnosis)
For your assistance and kind care
(Name of the family physician)
(Place of work of the family physician)
(Mobile number of the PHC unit or the referring physician)
(Signature of the family physician)
(A SPACE LEFT FOR THR RECEIVING PHYSICIAN FEEDBACK)