Cardiocare Multispecialty Hospital

5 Giza Close, Opp. FCDA/Ecobank, Area 11 Garki, Abuja, Nigeria

Tel: +234 817 444 5544 / +234 817 444 0888 · 24/7 emergency: +234 806 142 4614

Email: frontdesk@cardiocare.ng

Professional referral

Patient Referral Form

Referring facility & clinician

Referring facility
Referring clinician (role/title)
Contact phone
Contact email
Date
Urgency

Patient details

Full name
Date of birth / age
Sex
Patient contact number
Address

Clinical summary

Reason for referral / presenting complaint
Working diagnosis
Current medications & known allergies

Requested service

Investigations attached