FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS [ S.L.458.15 1 SUBSIDIARY LEGISLATION 458.15 FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS REGULATIONS 1st February, 1983 LEGAL NOTICE 54 of 1983, as amended by Legal Notice 426 of 2012. 1. The title of these Regulations is the Forms for Referral of Patients to Hospitals Regulations. Title. 2.
(1)The form to be used by a medical practitioner when referring a patient to a government hospital as an in-patient or outpatient, 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. Form for referral to hospital.
(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. Cap.
- 2 [ S.L.458.15 FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS SCHEDULE Amended by: L.N. 426 of
- (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 ............... .................................................................... .................................................................... Referred for ........................................ Tel. No. ................ (if any) To .............. Dept. Relevant Clinical History Treatment/Observations Signature .............................................. Date ....................... Name and Address (Printed or Block Letters) ..................................................................... ..................................................................... FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS [ S.L.458.15 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 3