Municipality of Goa
Rural Health Unit of Goa
Barangay __________________
REFERRAL SLIP
Date of Referral: _______________________
Name: ______________________________________________________________ Age: _________ Gender: ___________
Address: ____________________________________________________________Birthdate: _________________________
CC: ______________________________________________________________________________________________________
__________________________________________________________________________________________________________
Request/s for: ______________________________________________________________________________________________
Vital Signs: BP: ________ Temp: ________PR: ________RR:______ O2Sat: ________Wt: __________ Ht: __________
For OB Patients: G_____P______ (TPAL) ________________LMP:_________________ EDC: ______________________
AOG: ___________________________ FHT (If applicable): ___________________________________
Treatment/Intervention/s given: _______________________________________________________________________________
__________________________________________________________________________________________________________
Name of Medication/s given with date and time:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If Self-Medication ( write the name with date and time taken):
__________________________________________________________________________________________________________
Maintenance medication/s (if any) with date and time taken:
__________________________________________________________________________________________________________
Referred by: ________________________________________
Referred to: DIOSDADO G. FUENTEBELLA, MD / MARIO T. PAN, MD / ADRIAN CARLOS V. FAJARDO, MD
Municipality of Goa
Rural Health Unit of Goa
Barangay __________________
REFERRAL SLIP
Date of Referral: _______________________
Name: ______________________________________________________________ Age: _________ Gender: ___________
Address: ____________________________________________________________Birthdate: _________________________
CC: ______________________________________________________________________________________________________
__________________________________________________________________________________________________________
Request/s for: ______________________________________________________________________________________________
Vital Signs: BP: ________ Temp: ________PR: ________RR:______ O2Sat: ________Wt: __________ Ht: __________
For OB Patients: G_____P______ (TPAL) ________________LMP:_________________ EDC: ______________________
AOG: ___________________________ FHT (If applicable): ___________________________________
Treatment/Intervention/s given: _______________________________________________________________________________
__________________________________________________________________________________________________________
Name of Medication/s given with date and time:
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
If Self-Medication ( write the name with date and time taken):
__________________________________________________________________________________________________________
Maintenance medication/s (if any) with date and time taken:
__________________________________________________________________________________________________________
Referred by: ________________________________________
Referred to: DIOSDADO G. FUENTEBELLA, MD / MARIO T. PAN, MD / ADRIAN CARLOS V. FAJARDO, MD
