MATI Doctor Referral Slip ver02

REQUEST FOR REFERRAL SLIP
Date

MonthDayYear
Date
Is this your initial referral request?*

YesNo
Name of referring doctor*
Upload the copy of the request here*

Browse Files

Cancelof
Patient Classification*

EmployeeResidentFellowDependent
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
Gender1

MaleFemale
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
Date
Physician's Remarks

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

For Follow-upFor ReferralFor AdmissionFor Diagnostic ProcedureOther
Status
Cost
Should be Empty: