Table 1 Variables on the referral form to be completed during the referral
| Identification of referring officer | Health facility information | Patient identification details | Patient’s clinical information |
|---|---|---|---|
| Name of referring officer | Date |
Registration number (Unique identification number) | Presenting complaint(s) |
| Position | Name and address of referring facility | Name and address | Examination findings |
| Signature | Name and address of facility referred to | Sex | Investigation results |
| Date/Stamp | Time referred | Date of birth/Age | Diagnosis(es) |
| Time of departure (if emergency) | Health insurance status | Treatment given | |
| Name and address of contact person | Reason for referring to the next level | ||
| Phone number of contact person | Urgency of referral |