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					OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Quirino Avenue corner Roxas Boulevard Malate, Manila

INTERDEPARTMENTAL REFERRAL FORM NAME: GELI, James Hospital Number: 1863498 AGE/SEX: 13/M Room No.: 221 ADDRESS: Gate 10 Area B, Parola, Tondo, Manila DATEOF ADMISSION: July 23, 2008 ADMITTING DIAGNOSIS: Contusion Hematoma (Periorbital Area) OD Abrasion, Lateral Canthal Area OD Traumatic Mydriasis OD Absolute Eye OD PHYSICIANS-IN-CHARGE: Drs. Reyes/Sumajit/Samaniego/Ibasco/Tormon CLERKS-IN-CHARGE: Fabian/Ilarde/Ingles/Item/Junsay Referral to: Pediatrics Date referred: July 23, 2008 Reason for referral: For Co-management

___________________________ Referring M.D.

___________________________ Receiving M.D.

OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Quirino Avenue corner Roxas Boulevard Malate, Manila

INTERDEPARTMENTAL REFERRAL FORM NAME: GELI, James Hospital Number: 1863498 AGE/SEX: 13/M Room No.: 221 ADDRESS: Gate 10 Area B, Parola, Tondo, Manila DATEOF ADMISSION: July 23, 2008 ADMITTING DIAGNOSIS: Contusion Hematoma (Periorbital Area) OD Abrasion, Lateral Canthal Area OD Traumatic Mydriasis OD Absolute Eye OD PHYSICIANS-IN-CHARGE: Drs. Reyes/Sumajit/Samaniego/Ibasco/Tormon CLERKS-IN-CHARGE: Fabian/Ilarde/Ingles/Item/Junsay Referral to: Neurosurgery Date referred: July 23, 2008 Reason for referral: For neurosurgery clearance

___________________________ Referring M.D.

___________________________ Receiving M.D.

OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Quirino Avenue corner Roxas Boulevard Malate, Manila

INTERDEPARTMENTAL REFERRAL FORM NAME: AGE/SEX: ADDRESS: DATEOF ADMISSION: ADMITTING DIAGNOSIS: PROCEDURE: PHYSICIANS-IN-CHARGE: Drs. CLERKS-IN-CHARGE: Fabian/Ilarde/Ingles/Item/Junsay Referral to: Date referred: July 15, 2008 Reason for referral: Hospital Number: Room No.:

___________________________ Referring M.D.

___________________________ Receiving M.D.

OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Quirino Avenue corner Roxas Boulevard Malate, Manila

INTERDEPARTMENTAL REFERRAL FORM NAME: AGE/SEX: ADDRESS: DATEOF ADMISSION: ADMITTING DIAGNOSIS: PROCEDURE: PHYSICIANS-IN-CHARGE: Drs. CLERKS-IN-CHARGE: Fabian/Ilarde/Ingles/Item/Junsay Referral to: Date referred: July 15, 2008 Reason for referral: Hospital Number: Room No.:

___________________________ Referring M.D.

___________________________ Receiving M.D.

OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Quirino Avenue corner Roxas Boulevard Malate, Manila

INTERDEPARTMENTAL REFERRAL FORM NAME: AGE/SEX: ADDRESS: DATEOF ADMISSION: ADMITTING DIAGNOSIS: PROCEDURE: PHYSICIANS-IN-CHARGE: Drs. CLERKS-IN-CHARGE: Fabian/Ilarde/Ingles/Item/Junsay Referral to: Date referred: July 15, 2008 Reason for referral: Hospital Number: Room No.:

___________________________ Referring M.D.

___________________________ Receiving M.D.


				
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