Hospitals:
AKUH, Karachi
|
AKUH, Nairobi
Patient Referral Form
Patient Referral Guide
Patient Referral Form
Patient Referral Form
PATIENT'S DETAILS:
Patient's full name:
Initial:
*
First Name:
*
Middle Name:
Last Name:
*
::Select
Mr.
Mrs.
Ms.
Dr.
Sex:
*
Male
Female
Date of birth:
*
The patient is coming from:
*
to
(Ref. Hospital) (Rec. Hospital)
Has patient visited any other AKHS/AKUH(N) Network earlier for the same or any other complaint?:
*
Yes
No
If yes, please give patient's Medical Record Number (Reg. No):
/
/
Will the consultation required be for:
*
Inpatient Care?
Outpatient Care?
What treatment/procedure does the patient require? Please specify:
*
Have you already sent to Receiving Hospital patient’s medical history and medical problems, which require medications, e.g. diabetes, hypertension, heart diseases, etc., details of past operations, and hospitalisation and test reports of the patient:
*
Yes
No
If no, please fax it at (020) 3746309/ 3740729 or e-mail it at
Nooreen.dawoodani@aku.edu
urgently so that it can be reviewed by the doctor before the patient’s arrival.
Please provide Patient Contact Telephone numbers and Address:
Telephone No:
*
Address:
*
REFERRING PHYSICIAN’S DETAILS:
Full name of the doctor:
*
Complete mailing address:
Fax:
*
Telephone:
*
E-mail address:
*
RECEIVING PHYSICIAN’S DETAILS:
Full name of the doctor:
*
Complete mailing address:
Fax:
*
Telephone:
*
E-mail address:
*
FINANCIAL STATUS:
4.1 Which of the following category is applicable to the patient’s financial status?:
*
Self-pay-the patient would make cash payments for his/her treatment.
Patient’s medical expenses are covered by Corporate/HMO/Insurance Please also enclose a confirmation letter for financial coverage from the above if available.
Are you of the opinion that the patient will be able to meet the financial obligations?
OTHER INFORMATION:
Please provide any other information which you consider important regarding the treatment or stay of the patient at AKUH,N.
Aga Khan University Hospital, Nairobi
About Us
Hospital Services
For Patients and Visitors
Programmatic Areas
Patients Referral Procedure
The Princess Zahra Pavilion
Teaching and Research
Continuing Medical Education
Visitors
Feedback
News and Events
Career Opportunities
Contact Us
Manage Site
This is the official website of Aga Khan University. © Aga Khan University.
Unless specifically stated, extracts (other than photographs) may be reproduced without further permission, with due acknowledgment.
