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					OSPITAL NG MAYNILA MEDICAL CENTER CITY OF MANILA Interdepartmental Referral Sheet Patient’s Name: Macalagay Eva Hospital Number: 1709756 Age/Sex: 49/F Ward/Room: IM-425 Date referred: July 17, 2007 Attending Physician: Drs. De Leon, Sta.Maria, de los Reyes, Filio, Indon Diagnosis: CKD stage V 2 to DM Nephropathy
DM 2 HCVD, CM, NSR, II-B

Referred to: Department of Surgery Reasons for Referral: AV fistula creation

______Co-management ______Opinion and suggestion only ______Pre-operative evaluation (with pre-op form) ______Transfer of service ______Others

Opinion and suggestion:

Stat ____ Routine____

__________________________ Signature of Referring Physician

__________________________ Signature of Receiving Physician

OSPITAL NG MAYNILA MEDICAL CENTER CITY OF MANILA Interdepartmental Referral Sheet Patient’s Name: Bautista, Roberto Hospital Number: 1707869 Age/Sex: 65/M Ward/Room: IM-426 Date referred: July 17, 2007 Attending Physician: Drs. De Leon, Gonzales, Filio, Indon Diagnosis: CKD prob 2 to hypertensive nephrosclerosis
Clerk-in-Charge: Navarro/Ponelas/ Reyes

Referred to: Department of Surgery Reasons for Referral: AV fistula creation

______Co-management ______Opinion and suggestion only ______Pre-operative evaluation (with pre-op form) ______Transfer of service ______Others

Opinion and suggestion:

Stat ____ Routine____

__________________________ Signature of Referring Physician

__________________________ Signature of Receiving Physician


				
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