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CENTRAL VISAYAS HEALTH REFERRAL SYSTEM

The document contains referral forms for the CLARIN Main Health and TB DOTS Center and the CLARIN Birthing Center, detailing patient information, case summaries, and reasons for referral. Each form includes sections for the referring healthcare worker's details and a return referral slip for the receiving facility to complete. The forms emphasize the importance of retaining copies and attaching additional documentation as necessary.

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104 views2 pages

CENTRAL VISAYAS HEALTH REFERRAL SYSTEM

The document contains referral forms for the CLARIN Main Health and TB DOTS Center and the CLARIN Birthing Center, detailing patient information, case summaries, and reasons for referral. Each form includes sections for the referring healthcare worker's details and a return referral slip for the receiving facility to complete. The forms emphasize the importance of retaining copies and attaching additional documentation as necessary.

Uploaded by

smoothp3ak
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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CLARIN MAIN HEALTH AND TB DOTS CENTER REFERRAL FORM

Referred to:______________________________________________________________________________________
Address:_________________________________________________________________________________________
Date/Time Referred (ReCo):___________________________ Date/Time Transferred:_________________________
Name of patient:_________________________________________ Age:________ Sex:_________ Status:_________
(Surname) (First Name) (Middle Name)
Address:_________________________________________________________________________________________
PhilHealth Status: Member Dependent PhilHealth #___________________________________
Case Summary (pertinent Hx/PE, including meds, labs, course etc.):
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Summary of ReCo (pls. refer to ReCo Guide in Referring Patients Checklist) :
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Diagnosis/Impression: _____________________________________________________________________________
Reason for referral: _______________________________________________________________________________

Name of referring HCW: ___________________________________________________________________________


(Signature over Printed Name) (License #) (Mobile#)

REINA JANE V. DEMANDANTE, MD, MPA


MHO

Name of referred HCW-Mobile Contact # (ReCo): _______________________________________________________


Note: Referring Facility to retain duplicate copy, may attach additional sheet if necessary including lab results, x-ray etc.

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Return Referral Slip

Date & Time: ____________________

To: CLARIN MAIN HEALTH AND TB DOTS CENTER

Name of patient:_________________________________________ Age:________ Sex:_________ Status:_________


(Surname) (First Name) (Middle Name)
Address:_________________________________________________________________________________________
Date & Time Received (Patient):_____________________________________________________________________

Final Diagnosis/es:________________________________________________________________________________
________________________________________________________________________________________________
Action Taken: ____________________________________________________________________________________
Instruction/Recommendations: _____________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Printed Name and Signature MD/HCW – Mobile Contact # : ______________________________________________


Name, Address/contact number of Referred Hospital/Facility: ____________________________________________

Note: Return Referral Slip should be sent back to the referring facility after entering details in the referral logbook of the recipient facility.
CLARIN BIRTHING CENTER REFERRAL FORM

Referred to:______________________________________________________________________________________
Address:_________________________________________________________________________________________
Date/Time Referred (ReCo):___________________________ Date/Time Transferred:_________________________
Name of patient:_________________________________________ Age:________ Sex:_________ Status:_________
(Surname) (First Name) (Middle Name)
Address:_________________________________________________________________________________________
PhilHealth Status: Member Dependent PhilHealth #___________________________________
Case Summary (pertinent Hx/PE, including meds, labs, course etc.):
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Summary of ReCo (pls. refer to ReCo Guide in Referring Patients Checklist) :
________________________________________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
Diagnosis/Impression: _____________________________________________________________________________
Reason for referral: _______________________________________________________________________________

Name of referring HCW: ___________________________________________________________________________


(Signature over Printed Name) (License #) (Mobile#)

REINA JANE V. DEMANDANTE, MD, MPA


MHO

Name of referred HCW-Mobile Contact # (ReCo): _______________________________________________________


Note: Referring Facility to retain duplicate copy, may attach additional sheet if necessary including lab results, x-ray etc.

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------------

Return Referral Slip

Date & Time: ____________________

To: CLARIN BIRTHING CENTER

Name of patient:_________________________________________ Age:________ Sex:_________ Status:_________


(Surname) (First Name) (Middle Name)
Address:_________________________________________________________________________________________
Date & Time Received (Patient):_____________________________________________________________________

Final Diagnosis/es:________________________________________________________________________________
________________________________________________________________________________________________
Action Taken: ____________________________________________________________________________________
Instruction/Recommendations: _____________________________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Printed Name and Signature MD/HCW – Mobile Contact # : ______________________________________________


Name, Address/contact number of Referred Hospital/Facility: ____________________________________________

Note: Return Referral Slip should be sent back to the referring facility after entering details in the referral logbook of the recipient facility.

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