Hnru Referral Form
Hnru Referral Form
REFERRAL FORM
REFERRAL CATEGORY
EMERGENT URGENT NON-URGENT
PROVINCIAL HEALTH OFFICE REASON FOR REFERRAL
QMC Compound, Barangay 11, Lucena City TRANSFER OF SERVICE DIAGNOSTIC
E-mail: [email protected]
Contact Number: 09209228787 FB: Quezon HNRU OUTPATIENT CONSULTATION STEP DOWN CARE
SPECIFIC SERVICE:
_______________________________
Referring Facility
NAME OF HEALTH FACILITY
Rizal Street, Poblacion, Atimonan Quezon | 042-754-4582 | 0908-149-3556 | [email protected]
ADDRESS TIME
WITH ATTACHED CLINICAL RECORD WITHOUT ATTACHMENT REFER TO TREATMENT COURSE SUMMARY AT THE BACK, IF APPLICABLE
PLEASE RETURN THIS PORTION TO THE REFERRING FACILITY QUEZON PWHS FORM NO. 4a
NAME OF REFERRING FACILITY REFERRAL FORM
ADDRESS OF REFERRING FACILITY RETURN SLIP
PHONE NUMBER / EMAIL
DIAGNOSIS/
IMPRESSION
CONTENTS OF THIS DOCUMENT MAY FORM PART OF THE PATIENT’S PERSONAL HEALTH/ MEDICAL DATA
AND MAY BE PROTECTED UNDER THE DATA PRIVACY ACT.