RHAZES PATIENT REFERRAL FORM
This referral will be addressed to a Online / Offline Healthcare Professional Provider who provides a particular service. It will explain the medical reason why the patient is being referred to the Healthcare Professional Provider, and it will also include any relevant medical history, including allergies and medications.This form is to be filled by Rhazes Online Healthcare Professional Provider for referral case
Will the referral be internal or external
Internal
External
Select 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
Consultant Name
*
Consultant Organization
*
Consultant Email
*
example@example.com
Patient ID
*
Date
-
Month
-
Day
Year
Date
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PATIENT PERSONAL INFORMATION / MAKLUMAT PERSONAL PESAKIT
Patient Name / Nama Pesakit
*
Patient Email / Email Pesakit
*
example@example.com
Patient Mobile Phone Number / No Mobile Pesakit
*
Date of birth / Tarikh Lahir
-
Month
-
Day
Year
Date
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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
*
RHAZES TELEHEALTH @ RHAZES CONSULTANCY SERVICES SDN BHDWebsite : www.rhazesconsult.com / Email : rhazestelepharmacy@gmail.com / Whats'App 013-393 8042
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