S.L. 458.15 Art. 2Formforreferralto hospital. Cap. 458.

(1) The form to be used by a medical practitioner when referring a patient to a government hospital as an in-patient or out-patient, other than in the case of compulsory admission under the provisions of the Mental Health Act, shall be that as laid down in the Schedule.

(2) It shall be the duty of the said medical practitioner referred to in sub-regulation (1) to ensure that Part A of the said form is filled legibly and with all the necessary details.

(3) It shall be the duty of the medical practitioner at the hospital to which a patient has been so referred, and who has examined the patient or authorised his admission to the said hospital to ensure that Part B of the said form is filled legibly and with all the necessary details. SCHEDULE

(Regulation 2)

DEPARTMENT OF HEALTH

TICKET OF REFERRAL OF A PATIENT TO HOSPITAL

Part A To be filled by Medical Practitioner referring a patient to hospital.

Referral to .............................. Hospital

Hospital No. ............................. (if any)

Legally valid identification document number . .................. (if patient has a legally valid identification document) -------------------------------------------------------------------------------Name of patient ............................................. Age ......................

Address of patient .......................................... ..................................................................... Tel. No. ................ (if any) Name and address of nearest relative ............... .................................................................... Tel. No. ................ .................................................................... (if any) Referred for ........................................ To .............. Dept.

Relevant Clinical History Treatment/Observations

Signature .............................................. Date ....................... Name and Address (Printed or Block Letters) ..................................................................... ..................................................................... Part B

FOR OFFICIAL USE ONLY

To be filled by medical officer examining or admitting the patient. Occupation of (1) patient .......................................................

(2) head of household ......................................

National Insurance Number ........... Legally valid identification document number . ............... (if patient has a legally valid identification document) or Public Registry No. if any)

Date of Birth of Patient ............................................. Name and Surname of parents (if deceased, write 'late' in front of name) ....................................................................................................... .......................................................................................................

Patient admitted to ............................ ward on .............................. at ........................ a.m./p.m.(to be filled only in case of admission.)

.............................................................. Signature of medical officer

.............................................................. Name in Block Letters

............................................ Date