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|
|
CONSULTATION |
|
| Patient Name | [PatientName] [Sex] / [Age] | Patient ID | [PatientID] | ||
| Ward | [Ward] | Room/Bed | [Bed] | IP NO | [IPNO] |
| Ref.By. | Dr. [ReqBy] | Dept. | [ReqByDept] | Ref.To. | Dr. [RefTo] | Dept. | [RefToDept] |
| CONSULTATION REQUEST(Case summary and reason for request) | [ROUTINE]ROUTINE | [URGENT]URGENT | [EMERGENCY]EMERGENCY | |
|
[REMARKS]
|
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| Date | [ReqDate] |
Name and Signature of Doctor
Dr. [ReqBy]
|
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| CONSULTATION REPORT(Notes and Recommendations) |
|
[NOTES]
|
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| Date | [ReqToDate] |
Name and Signature of Doctor
Dr. [ReqToDr]
|
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| LHRC/IPD/02 |