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Pmcare Referral Form: Page 1 of 1

This document is a referral form from a clinic to an ophthalmologist. It provides information about a patient being referred such as name, date of birth, gender, diagnosis, and reason for referral.

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Poi Jia Yang
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30 views1 page

Pmcare Referral Form: Page 1 of 1

This document is a referral form from a clinic to an ophthalmologist. It provides information about a patient being referred such as name, date of birth, gender, diagnosis, and reason for referral.

Uploaded by

Poi Jia Yang
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Revision 1

PMCARE REFERRAL FORM

Reference No. : 20220122P001820

To : DR STEPHEN CHUNG SOON

Specialty : OPHTHALMOLOGY

Hospital Name : COLUMBIA ASIA HOSPITAL SETAPAK

Dear Doctor,

Patient Name : Mohd Ridzuan Bin Hamdan Patient I/C No. : 810726145239

Patient Date of Birth : 26/07/1981 Gender : Male

History : WATERY EYES LEFT

? BLOCKED TEAR DUCT

Provisional Diagnosis : OTHER CHANGES OF LACRIMAL PASSAGES


Reason for Referral : WATERY EYES

Other details (if any) : NIL

Thank you.

Referring Doctor : DR AZIZ ABU BAKAR

Clinic Name : KLINIK FAMILI SETAPAK


Clinic Code : 101895

Date of Visit : 22/01/2022

GL shall be forwarded to the hospital.

GL to be faxed or email to the member as follows:

Fax No. / Email :

PMCARE SDN BHD (458443-P)


No.1 Jalan USJ 21/10, UEP Subang Jaya, 47630 Selangor, Malaysia
Careline : 1-300-88-6868 Live DA Fax : 03-8023 3888

Page 1 of 1

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