FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS [ S.L.458.15 1
SUBSIDIARY LEGISLATION 458.15
FORMS FOR REFERRAL OF PATIENTS TO 
HOSPITALS REGULATIONS
1st February, 1983
LEGAL NOTICE 54 of 1983.
Title.
Patients to Hospitals Regulations.
Form for referral to 
hospital.
Cap. 262.
2. (1) The form to be used by a medical practitioner when
referring a patient to a government hospital as an in-patient or out-
patient, other than in the case of compulsory admission under the
provisions of the Mental Health Act, shall be that as laid down in
the Schedule.
(2) It shall be the duty of the said medical practitioner referred
to in subregulation (1) to ensure that Part A of the said form is
filled legibly and with all the necessary details.
(3) It shall be the duty of the medical practitioner at the
hospital to which a patient has been so referred, and who has
examined the patient or authorised his admission to the said
hospital to ensure that Part B of the said form is filled legibly and
with all the necessary details.
2 [ S.L.458.15 FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS
SCHEDULE
(Regulation 2)
DEPARTMENT OF HEALTH
TICKET OF REFERRAL OF A PATIENT TO HOSPITAL
Part A
To be filled by Medical Practitioner referring a patient to
hospital.
Referral to .............................. Hospital 
Hospital No. .............................
(if any)
I.D. Card No. ...........................
(if patient has an Identity Card) 
Name of patient .............................................  Age ......................
Address of patient ..........................................
..................................................................... Tel. No. ................
(if any)
Name and address of nearest relative ...............
.................................................................... Tel. No. ................
.................................................................... (if any)
Referred for ........................................  To .............. Dept.
Relevant Clinical History
Treatment/Observations
Signature .............................................. 
Date ....................... Name and Address (Printed or Block Letters)
.....................................................................
.....................................................................
FORMS FOR REFERRAL OF PATIENTS TO HOSPITALS [ S.L.458.15 3
Part B
FOR OFFICIAL USE ONLY
To be filled by medical officer examining or admitting the patient.
Occupation of  (1) patient .......................................................
(2) head of household ......................................
National Insurance Number ............... Identity Card No. ............
(if patient has an Identity
Card or Public Registry
No. if any)
Date of Birth of Patient .............................................
Name and Surname of parents (if deceased, write 'late' in front of
name)
.......................................................................................................
.......................................................................................................
Patient admitted to ............................ ward on ..............................
at ........................ a.m./p.m.(to be filled only in case of admission.)
..............................................................
Signature of medical officer
..............................................................
Name in Block Letters
............................................
Date
