REFERRAL

							OSPITAL NG MAYNILA MEDICAL CENTER CITY OF MANILA Interdepartmental Referral Sheet Patient’s Name: BALUBAL, Grace Age/Sex: 37/F Date referred: July 27, 2007 Attending Physician: Drs.Lucero/Aguila/Raceno/Dimaandal Diagnosis: ASA toxicity, and accidental alcohol intoxication
t/c adjustment disorder

Hospital Number: 1655318 Ward/Room: IM-INF

Referred to: Department of Psychiatry Reasons for Referral: further evaluation and management of depression

______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