Transplant Referral

New patient referral
Patient

First nameLast name
ID number
Patients phone number

Area codePhone number
Patients email address
example@example.com
Birth date

DayMonthYear
Gender
Alternative Contact

First nameLast name
Relation to patient
Phone number of alternative contact

Area codePhone number

Referring clinician
Referring clinician

First nameLast name
Clinician E-mail address
example@example.com
Institutional or departmental E-mail address
Phone number

Area codePhone number
Speciality

Other
Location

Referral details

Working diagnosis
What is the working diagnosis and reason for referral

Imaging investigations
Select the investigations that have been done:
Are these investigations on PACS (i.e. done in a Western Cape Provincial Hospital)
Where were the investigations done?
Radiology reports

Browse Files

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