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    Dr. Nicanor Reyes Medical Foundation Medical Center: Referral Forms/Consultation Form

    Uploaded by

    Araw Gabi
    The document contains 4 referral forms from different physicians at Far Eastern University Dr. Nicanor Reyes Medical Foundation referring patient Juan Pedro Dela Cruz to Dr. Reyes. Each form provides the referring and receiving physicians, reason for referral, date and time, patient information, and attending physician. The referrals are for evaluation, co-management, opinion, and home case endocrinology.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    Dr. Nicanor Reyes Medical Foundation Medical Center: Referral Forms/Consultation Form

    Uploaded by

    Araw Gabi
    86 views5 pages
    The document contains 4 referral forms from different physicians at Far Eastern University Dr. Nicanor Reyes Medical Foundation referring patient Juan Pedro Dela Cruz to Dr. Reyes. Each form provides the referring and receiving physicians, reason for referral, date and time, patient information, and attending physician. The referrals are for evaluation, co-management, opinion, and home case endocrinology.

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    REF from HM 5

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    The document contains 4 referral forms from different physicians at Far Eastern University Dr. Nicanor Reyes Medical Foundation referring patient Juan Pedro Dela Cruz to Dr. Reyes. Each form provides the referring and receiving physicians, reason for referral, date and time, patient information, and attending physician. The referrals are for evaluation, co-management, opinion, and home case endocrinology.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    86 views5 pages

    Dr. Nicanor Reyes Medical Foundation Medical Center: Referral Forms/Consultation Form

    Uploaded by

    Araw Gabi
    The document contains 4 referral forms from different physicians at Far Eastern University Dr. Nicanor Reyes Medical Foundation referring patient Juan Pedro Dela Cruz to Dr. Reyes. Each form provides the referring and receiving physicians, reason for referral, date and time, patient information, and attending physician. The referrals are for evaluation, co-management, opinion, and home case endocrinology.

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    © All Rights Reserved
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    Far Eastern University

    Dr. Nicanor Reyes Medical Foundation REFERAL


    FORM
    Medical Center FRONT PAGE

    TO: Physician/Department FROM : Referring Physician/ Department


    Dr. Reyes (baliktad) Dr. Macapagal

    Referral: Reason for referral:


     Evaluation  co-management  transfer of service
    Date: 7/23/20 Cardio-pulmonary/Endocrine  opinion  Others:_________
    Time: 10 :45 AM  PM Neurologic/others:________

    Patient’s Name: (Last,First,Middle) Date of Birth Age Gender Civil status Registration no.
    DELA CRUZ, JUAN PEDRO __/__/__ F SMW 57772772
    MM/DD/YY
    M DivSep
    Attending Physician: Department Room Bed No.
    DR. REYES

    REFERRAL FORMS/CONSULTATION FORM


    Far Eastern University
    Dr. Nicanor Reyes Medical Foundation REFERAL
    FORM
    Medical Center FRONT PAGE

    TO: Physician/Department FROM : Referring Physician/ Department


    Dr. Reyes (BALIKTAD) Dr. Benudez

    Referral: Reason for referral:


     - Evaluation  co-management  transfer of service
    Date: 7/23/20 Cardio-pulmonary/Endocrine  opinion  Others: home case endo________
    Time: 12:08 AM  PM Neurologic/others:________

    Patient’s Name: (Last,First,Middle) Date of Birth Age Gender Civil status Registration no.
    DELA CRUZ, JUAN PEDRO __/__/__ F SMW 57772772
    MM/DD/YY
    M DivSep
    Attending Physician: Department Room Bed No.
    DR. REYES
    REFERRAL FORMS/CONSULTATION FORM
    Far Eastern University
    Dr. Nicanor Reyes Medical Foundation REFERAL
    FORM
    Medical Center FRONT PAGE

    TO: Physician/Department FROM : Referring Physician/ Department


    Dr. Reyes Dr. Orata

    Referral: Reason for referral:


     Evaluation  co-management  transfer of service
    Date: 7/23/20 Cardio-pulmonary/Endocrine  opinion  Others:_________
    Time: 12:20 AM  PM Neurologic/others:________

    Patient’s Name: (Last,First,Middle) Date of Birth Age Gender Civil status Registration no.
    DELA CRUZ, JUAN PEDRO __/__/__ F SMW 57772772
    MM/DD/YY
    M DivSep
    Attending Physician: Department Room Bed No.
    DR. REYES
    REFERRAL FORMS/CONSULTATION FORM
    Far Eastern University
    Dr. Nicanor Reyes Medical Foundation REFERAL
    FORM
    Medical Center FRONT PAGE

    TO: Physician/Department FROM : Referring Physician/ Department


    Dr. Reyes Dr. Dela Cancu

    Referral: Reason for referral:


     Evaluation  co-management  transfer of service
    Date: 7/23/20 Cardio-pulmonary/Endocrine  opinion  Others:_________
    Time: 2:30 AM  PM Neurologic/others:________

    Patient’s Name: (Last,First,Middle) Date of Birth Age Gender Civil status Registration no.
    DELA CRUZ, JUAN PEDRO __/__/__ F SMW 57772772
    MM/DD/YY
    M DivSep
    Attending Physician: Department Room Bed No.
    DR. REYES
    REFERRAL FORMS/CONSULTATION FORM

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