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Health Sector-———-— REFERRAL & CONSULTA Health Center Date TS Na, nt Age cee tone sx Oe Ts tose F ” 5yLlay WL! jON FOR ig pSlpall upisisd aokeHoylot Abbie eoall yall aolailazro! goal gloat pei : bes sas Drasbinds Denali ed Spe asia Bs agi Jini aa a Immediate [] tas Urgent [2m elective [_] ease : cf mers Other [___] 55" Private car[_] +++ t= Ambulance [_Joe=" + v2) tS Any Tame of referra EISE PATIENT CONDITION Of REFERRAL; PRD Ys aie phat ate ws Clinical examination Complaint & duration Meike aS! Temp Bp Resp.rate Pulse Wieght Height BMI : sv Eps! yaorall Investigation (Included) ‘Summary Of interventions Provisional Diagnosis ... Treatment Given ~~ (Time of last dose) Reason of referral Follow Up [Jam Annual epeckup [Jas na wg) Danes dmareperece [J ySnasneaoe Genera ehcp [“] tons Upon Pavents Request [“] sets ey BY Stamp & Sign of treating Physician Stamp & Sign of technical director J AagBsSg Tat tan iS | dndsg ASN post SS

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