Fields marked (*) are required.

  • External Referral Procedure Referral
  • Routine
  • In-Patient ICU  

  • PART A (To be filled by Most Responsible Physician)

  • Kindly examine and advise. Thank you.Stamp and signature of the Most Responsible Physician.

  • * DEFINITIONS Consultation only: Consultant is asked to make an assessment and management suggestions.

    Consultation with directive care: The consultant assists with the ongoing care of the patient including appropriate orders and follow up. The consultant is not the most responsible physician.

    Consultation with continuing care: Consultant takes over the entire care of the patient and becomes the Most Responsible Physician