MATI Doctor Referral Slip ver02

REQUEST FOR REFERRAL SLIP
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Is this your initial referral request?
Name of referring doctor
Upload the copy of the request here

Browse Files

Cancelof
Patient Classification
Physician
Physician validation (Click validate to auto-generate doctor's info)
Clinic Room# {clinicRoom}, Schedule: {schedule} {time}, Contact# {telNumber}

NOTICE: Doctors’ clinic schedule is subject to change without prior notice to EHWC. Confirm and secure your appointments first prior LOA application.
NAME
Clinic Room#
Schedule
Time
TEL. NUMBER
Employee Information
HMO/Policy/Employee No.
Employee No.
Employee Name
Cost Center
Classification
Age:
Gender:
Patient Information
Type a question
Patient Name
Last Name, First Name M.I.
Gender
Birth Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Gender1
Age
Reason/s for Referral or Chief Complaint
Email Address
A copy of your referral slip will be sent here. Please use your CORPORATE EMAIL (@themedicalcity.com) or a GMAIL email address.
Approved?
Reason for Disapproval
Valid until

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Physician's Remarks

This section is for physician's use only
Email Address2
Final Diagnosis
Recommendations
Action Taken

Other
Status
Cost
Should be Empty: