Republic of the Philippines
Province of Camarines Sur
Municipality of MInalabac
BARANGAY ____________________
BARANGAY REFERRAL SLIP
Referred to: ____________________________________________________ Date: _________________ Time: ________
Address of Facility __________________________________________________________________________________
Patient Name: ______________________________________________________________ Age: ___________________
Sex: _____________ Status: _______________ Occupation: _________________________________________________
Address of Patient: __________________________________________________________________________________
Chief complaint / History of present illness / Assessment:
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Vital Signs:
BP:_______________ HR:_________ RR:_________ Temp:_________O2 Sat:_________ Wt:_________ Ht:__________
Management Given (Medication given, Laboratory, Diagnosis Procedures)
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Referred by:
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Signature over Printed Name
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RETURN SLIP
To: ______________________________ Date: _____________________ Time: _________
Name of Patient:________________________________________________________ Age: __________ Sex: ________
Address:__________________________________________________________________________________________
Final Diagnosis: _____________________________________________________________________________________
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Management: (Medication, Diagnostic Procedure, Definitive Procedures)
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Instruction/ Recommendation: (Including follow ups, preventive actions to be undertaken)
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Noted by:
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Signature over Printed Name Signature over Printed Name
Republic of the Philippines
Province of Camarines Sur
Municipality of MInalabac
BARANGAY ____________________
Attending Physician Medical Specialist/ COH
