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Referral - INTERNATIONAL REFERRAL FORM
Please help us serve you better by filling in the following information:-
CONTACT DETAILS
Name of Contact
Address
Telephone
Fax
Email
PARTICULARS OF PATIENT
Name of Patient
Date of Birth (dd/mm/yyyy)
Gender
Male Female
Nationality
Passport Number
Address
Telephone
Fax
Email
HISTORY AND CURRENT CONDITION
Does the Patient require Intensive Care facilities?
Yes No
Does the Patient have any infectious illness?
Yes No
Is the Patient HIV positive?
Yes No
Diagnosis of Medical Condition
Current Condition of Patient: In Hospital - Critical Condition
In Hospital - Stable Condition
On Outpatient follow-up
Other. Please specify
Details of Current Treatment/Medication :
Name of Referring Party:
Doctor-in-charge:
Telephone:
Fax:
Contact Person:
Telephone:
Fax:
Name of Medical Evacuation Company (if applicable)
Doctor-in-charge:
Telephone:
Fax:
Contact Person:
Telephone:
Fax:
(Please fax any copies of medical reports, test results and/or doctor's referral letter to
International Patient Services at Fax No: +65 6836-2627
OTHER SERVICES REQUIRED
Limousine Ambulance Service
Please arrange for an ambulance to pick the patient up from the airport.
We will also require the following :
Wheelchair
Stretcher
Other Equipment. Please specify
AIRPORT PICKUP
Please arrange to pick up the patient and family from the airport.
My flight details are:
Flight Number
Date of Arrival (dd/mm/yyyy)
Est. Time of Arrival (AM/PM)
Class of Ward
HOTEL ACCOMMODATION
Please arrange for my hotel accommodation as follows:
Name of Hotel (if any)
Number of Rooms
Single Double
Check-in Date (dd/mm/yyyy)
Check-out Date (dd/mm/yyyy)
My budget (room rate per night) is :
Less than US$100+++ (plus 19% plus 4% plus 1%)
Between US$100+++ to US$150+++
Between US$150+++ to US$200+++
US$200 and above
OTHER INFORMATION / REMARKS
GUARANTEE
The Referring Party has informed and confirmed that patient is prepared to place a deposit of USD: or SGD: prior to admission via telegraph transfer (T/T) of funds
Yes No
Medical Report:
Please note:
Please fax this completed form together with any other supporting documents to Fax No:+65 6836-2627 for co-ordination purposes.
It is very important to indicate the discipline as this will facilitate faster and more efficient co-ordination activities.