Referral Patient Non Seha – Sheikh Shakhbout Medical City Abu Dhabi

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📋 Patient Data 🏥 Referral Details 💊 Medical Condition

Section 1: Patient Data

Full Name*

Date of Birth*

Age*

Gender*

Emirates ID/Passport No.*

Emirates ID/Passport Upload*

MRN No*

Referring Facility*

Nationality*

Emergency Contact Number/Next to Kin*

Accepted formats: 501413429 (9 digits) or +971501413429 (with country code)

Relationship with Emergency Contact*

Employer*

Insurance Provider*

Section 2: Referral Details & Diagnosis

Please provide detailed information about the referral and patient diagnosis.

Referral Date/Time*

Reason for Transfer*

Primary Diagnosis*

Is the service requested available at your facility?*

Police Case?*

Motor Vehicle Accident (MVA)?*

Admission within last 6 months to hospital?*

Section 3: Medical Assessment & Clinical Details

Treatment abroad in last 6 months?*

Victim or war, gunshot, or blast?*

Colonized with MDROs (Carbapenem resistant Organisms, MRSA, VRE, or ESBL)?*

Colonized with Candid auris?*

Clinical Urgency for transfer*

Section 3: Patient Medical Condition

Current Location*

Airway Support*

Circulation Support*

Vital Signs

Blood Pressure (BP)*

Heart Rate (HR)*

Respiratory Rate (RR)*

Oxygen Saturation (Sat O2)*

Temperature*

GCS*

Intubated/Tracheostomy*

Referring Hospital*

Referring Nursing supervisor or Referral Centre contact No*

Accepted formats: 501413429 (9 digits) or +971501413429 (with country code)

Emirates*

The information you send will be uploaded to the patient's medical record.

Fields marked with (*) are mandatory