Eastern Visayas Medical Center - Emergency Medical Services Unit
Nearby clinics
Real Street Brgy. 25
Brgy. Bagacay
6500
Bagacay
Brgy. Bagacay
Bagacay
Brgy. 93 Bagacay
Bagacay
6500
Brgy. 93 Bagacay
Emergency Medical Services Unit
To all referring facilities, kindly use this template for referrals to EVMC. If possible, we appeal to all facilities in using/creating an account named under your hospital/RHU/rescue unit when sending templates to our account Ems, otherwise you can directly text our hotline number 0928-388-7722. Thank you!
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REFERRAL FORM
Referring Facility:
Contact Number:
Name of Physician: Dr.
Name of patient:
Age:
Birthday:
Gender:
Religion:
Nationality:
Occupation:
Present Address:
Province:
Municipality/City:
Barangay:
Date & History of Travel(past 14 days):
Pre existing condition:
Chief complaint:
Signs & Symptoms:
Date of Admission:
RTPCR:
Swabbed date:
Date of result:
Rapid Antigen Test:
Date of result:
Contact details of pt:
*Diagnosis:
Vital Signs
BP
HR:
RR:
Temp:
O2 sat%
GCS (EVM):
Management done:
Medicine given:
Laboratories:
Reason for Referral:
Vaccination status:
Vaccine:
Date of doses given:
1ST DOSE=
2ND DOSE=
Booster:
Name of Caller/Informant:
To ALL Referring Facilities in the region...
We appeal to you to create only 1 messenger account for all your referrals.
We also discourage using personnal messenger account in referring as we are having hard time to search who referred coz we only record the name of the facility...
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Category
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Tacloban City
6500
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