CONSULTATION / PROCEDURE REFERRAL FORM Fields marked (*) are required. Patient Name:* MRD No:* Sex:* Male Female DOB:* Tel No:* From (Referring Doctor):* Select a doctor Bashar Sahar Dr Abdul Razzak Juratli Dr Abdullah Davoodbhoy Dr Abeer Abdel Aaty Soliman Dr Adel Abushi Dr Adel Ahmed El Naggar Dr Adel Eryani Dr Aditya Bhabhe Dr Ahmad Abdul Rahman Dr Ahmed Al Kamali Dr Ahmed Awad Salim EL-Hakeem Dr Ahmed ElMansoury Dr Ahmed Ibrahim Mostafa Dr Ahmed Mohammed Al Kamali Dr Akhilesh Sapra Dr Ali Al Ghrebawi Dr Amna Naveed Dr Amro Kabakbjy Dr Anoop Kumar Joshi Dr Archana Nair Dr Arif Adenwala Dr Arif Al Nooryani Dr Arun Kunhiraman Dr Ashar Jamal Dr Ashley Thomas Dr Ashraf Ahmed Shatla Dr Ayman Moustafa Hassan Dr Bahaa Al Nashi Dr Bassam Hasan Dr Bassam Mikaiel Toubal Dr Bassant Amer Dr Betty John Dr Bobby Jose Dr Brian Mtemererwa Dr Deepak Bhatia Dr Deepika Gandhi Dr Dena Mohamed Abdel Raof Dr Dena Samir Abdelhady Dr Dinesh Vaidya Dr Edgar Edmond Irany Dr Ehsan Ahmad Dr Elias Sayegh Dr Emad Mohammed El Shafie Dr Emadeldin Ibrahim Dr Fadil Al Azzawi Dr Faheem Tadros Dr Harith Hamdan Dr Hazem Daaji Dr Hazim K. Al Mance Dr Hermann Ulrich Honemeyer Dr Hoda Ismail Dr Hossameldin Maged Dr Ihab El Tayeb Dr Israa Khalid Dr Kamal Hussein Saleh Dr Karim Antoine Attara Dr Kausar Perveen Dr Khalid Ali Khan Dr Kowshik Gupta Dr Lakshamana Rajan Dr Lilly Jose Dr Loai Eid Dr M Sona Rajan Dr Mah Sheena K Mohammed Dr Maha Shahin Dr Mais Ibrahim Dr Manal Saad Dr Manjiri Bapat Dr Manoj Singh Dr Manoja Widanagama Dr Medhat Habib Dr Milind Raje Dr Mohamad Abdulkader Karima Dr Mohamad Azzam Ziade Dr Mohamed Adel Abo Ghanima Dr Mohamed Fahmy Dr Mohamed Zedan Dr Mohammad Al Hasoun Dr Mohammad Aldisi Dr Mohammad Horan Dr Mohammed Istrabadi Dr Mohammed Riffat Alsharaky Dr Mona Omar Suleiman Dr Mona Zakariya Dr Mustafa Hassan Marai Dr N. Selvakumari Dr Nawal Ibraheem Dr Nawras Mohammad Al Hawa Dr Nazim AlRifai Dr Nidhi Panwar Dr Nisha Soares Dr Nishanth Sanalkumar Dr Osama Batal Dr Pawan Nath Dr Piyush Somani Dr Prachet Kulkarni Krishnamurthy Dr Prem Tanwar Dr Priya Besekar Dr Rabab Mehdi Hilmy Dr Rafik Abu Samra Dr Ram Shukla Dr Riadh Khudhier Dr Ricardo A. P. Persaud Dr Rim Kharis Dr Rizmee Shireen Dr Roleen Pereira Dr Rupesh Singh Dr Saeid Taghizadeh Dr Saji Sreedharan Pillai Dr Saji Varghese Dr Salahudeen Fizal Dr Saleh Al Basha Dr Samar Ali Dr Sameh Ali Dr Samia Wadie Samy Dr Sanjiv Kumar Kakkar Dr Shahzada Zubair Dr Shaju George Dr Shama Nawaz Dr Shamail Suliman Shaheen Dr Shekhar V. Shikare Dr Sherief Elsayed Dr Shwan Hameed Dr Shyamsunder Nair Dr Sukrith Shetty Dr Sukriye Julide Sagirolu Dr Sulfi Rahumathulla Dr Syed Rabbani Dr T. Sathish Kumar Dr Tagore Grandhi Dr Taimaa Shtayyan Dr Tarek Mustafa Abd Elhamid Dr Vinita Jain Dr Waha Adi Dr Wedad Nabih Ahmed Dr Wissam Jamal Al Tamr Dr Zulqarnain Kazim Anjum Dr. Ateesh Borole Dr. Biju Pankappilly Dr. Dev Roy Dr. Dhaval Darji Dr. Fadel Husrom Dr. Fekry ElDeeb Dr. Gene Ann Thomas Dr. Hala Khalifa Dr. Hala Maher Dr. Hiba Alla Maskji Dr. Jabir R Hameed Dr. Jayasheela Kannan Dr. Khaled Faraj Dr. Mohamed Abou Koutah Dr. Mohammed Mustafa El Mahy Dr. Mohammed Sala Uddin Dr. Mohammed Shabbir Dr. Nancy Nabil Dr. Nile Abo Baker Dr. Nusaiba Ghanem Dr. Pooja Agrawal Dr. Pramod Subash Dr. Rajan Maruthanayagam Dr. Rajeev Kamble Dr. Renuka Joshi Dr. Rohit Raja Dr. Shalini Shanmugam Dr. Sirar Al Ali Dr. Suvadip Chatterjee Dr. Syed Adnan Dr. Tamer Saafan Dr. Venkatesh Manchikanti Dr. Walid Shaker Dr. Yasser Menaissy Dr. Yassin Malallah Al Musawi Mr. Mirshad Vattiyam Veettil Mr. Rhandy M Navarro Mr. Vimal Kurian Ms Khatheeja Basheer Ms Mays Marwan Al Belbais Ms. Ani Varghese Ms. Divya Prabhu Ms. Dona Dolly Thomas Ms. Jinjumol P Mathew Ms. Meethu Thomas Ms. Safina Khan Ms. Sophia Jogi Referred To:* Referred Date and Time:* Type of referral:* Internal Referral External Referral Procedure Referral Category:* Urgent Routine Referral As:* OPD In-Patient ICU Type of Consultation:* Consultation Only Consultation with Directive Care Consultation with Continuing Care Transfer PART A (To be filled by Most Responsible Physician) Reason for referral and clinical details: Kindly examine and advise. Thank you.Stamp and signature of the Most Responsible Physician. Signature Date and time * 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
