Patient referral template

Patient Referral Letter

Date: Date

Dear Receiving Specialty Colleague at Receiving Facility,

We refer to you Patient Name, record no. Medical Record Number, age Age, for assessment and management of Reason for Referral. Working diagnosis: Working Diagnosis. Current treatment: Current Treatment. Priority: Urgent / Routine.

Thank you for your cooperation.

Referring physician: Physician Name

Signature: Signature

Stamp: Stamp