[Hospital Name]
[HospitalAddr1][HospitalAddr2]
[HospitalAddr3]
[HospitalAddr4]
[HospitalPhone]
[HospitalEmail]
[HospitalWeb]
[Hospital Name][HospitalAddr1][HospitalAddr2] [HospitalAddr3] [HospitalAddr4] [HospitalPhone] [HospitalEmail] [HospitalWeb] |
|
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]
|
|||||
| Date | [ReqDate] |
Name and Signature of Doctor
Dr. [ReqBy]
|
|||
| CONSULTATION REPORT(Notes and Recommendations) |
|
[NOTES]
|
|||||
| Date | [ReqToDate] |
Name and Signature of Doctor
Dr. [ReqToDr]
|
|||
| LHRC/IPD/02 |