RHAZES PATIENT REFERRAL FORM
This referral form is designed for use by all healthcare professionals on the Rhazes TeleHealth platform. It will be: 1. Directed to online or offline healthcare professional providers offering a specific service. 2. Used to explain the medical reason for the referral. 3. Inclusive of relevant medical history, such as allergies and current medications. 4. Completed by Rhazes Online Healthcare Professional Providers. 5. Provided to patients for serious or secondary cases requiring further care.
Will the referral be internal or external
Internal
External
Choose a Healthcare Professional to refer to
*
Please Select
Ahlam Sundus
Ahmad Fadhullah Fuzai
Ahmad Hakimi
Dr Baharudin Ibrahim
Dr Shariza Sahudin
Dr Yaman Walid Kassab
Dr Zaswiza Mohamad Noor
Benny Chian
Chan May May
Chiew Eng Seah
Daleelah Md Nor
Datuk Chan Hian Kee
Dr Ernieda Md Hatah
Dr Erwin Martinez Faller
Dr Mahmathi A/P Karuppannan
Dr Mohamed Hassan Abdelaziz Elnaem
Dr Mohd Shahezwan Abd Wahab
Munaver
Professional Healthcare Provider Name
*
Professional Healthcare Provider Email Address
*
example@example.com
Patient ID
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PATIENT INFORMATION / MAKLUMAT PESAKIT
Patient Name / Nama Pesakit
*
Patient Email / Email Pesakit
*
example@example.com
Patient Mobile Phone Number / No Mobile Pesakit
*
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PATIENTS DETAILS / BUTIRAN PESAKIT
Patient's Medical History / Sejarah Perubatan Pesakit
*
Patient's Allergies (if any) / Alahan Pesakit , Jika ada
*
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REFERRAL DESCRIPTION
Please used SOAP Guidelines
REASON FOR REFERRAL
*
All Rhazes Online Healthcare Professional Providers are advised to refer to SOAP guidelines
Title / Name / Designation / Organization
REFERRER INFORMATION
REFERRER PROFESSIONAL REGISTRATION NUMBER
*
Reference Date
-
Month
-
Day
Year
Date
RHAZES TELEHEALTH INTERNATIONAL SDN BHD Website : www.rhazesconsult.com Email : admin@rhazestelehealth.com / Whats'App 013-393 8042
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