21/06/2023
To all referring facilities, kindly use this template for referrals to EVMC. If possible, we appeal to all facilities in using/creating an account named under your hospital/RHU/rescue unit when sending templates to our account Ems, otherwise you can directly text our hotline number 0928-388-7722. Thank you!
--------
REFERRAL FORM
Referring Facility:
Contact Number:
Name of Physician: Dr.
Name of patient:
Age:
Birthday:
Gender:
Religion:
Nationality:
Occupation:
Present Address:
Province:
Municipality/City:
Barangay:
Date & History of Travel(past 14 days):
Pre existing condition:
Chief complaint:
Signs & Symptoms:
Date of Admission:
RTPCR:
Swabbed date:
Date of result:
Rapid Antigen Test:
Date of result:
Contact details of pt:
*Diagnosis:
Vital Signs
BP
HR:
RR:
Temp:
O2 sat%
GCS (EVM):
Management done:
Medicine given:
Laboratories:
Reason for Referral:
Vaccination status:
Vaccine:
Date of doses given:
1ST DOSE=
2ND DOSE=
Booster:
Name of Caller/Informant:
