INTERNATIONAL  MEDICAL SERVICE PATIENT REFERRAL FORM

GENERAL PATIENT INFORMATION First Name : Last Name : Address : City : Country : Postal Code : Telephone (Home) : Telephone (Work) : Fax : Religion : Date of Birth (month/day/year) : If other than patient or physician, person completing this form: First Name : Last Name : Relation :	REFERRING PHYSICIAN INFORMATION First Name : Last Name : Address : City : Country : Postal Code : Specialty : Telephone(s) : Fax : E-mail :
REASON FOR CONSULTATION Emergency Confirm a Diagnosis/Second Opinion Seek a Diagnosis Seek Treatment Other	DOES THE PATIENT REQUIRE CIRITCAL CARE TRANSPORT? Yes No
PATIENT MEDICAL INFORMATION Chief Complaint / Current Diagnosis : Previous Examination(s) Performed X-Rays, Date : Ultrasound, Date : Surgery, Date : Magnetic Resonance Imaging (MRI), Date :  Angiography, Date : Scan, Date : Other(s) Past Medical History (Include any relevant information such as history of diabetes, heart disease, past surgeries, alcohol use, tobacco use, etc. ): Current Medications (name, dosage, frequency):	ADDITIONAL INFORMATION Person who will accompany patient to UAB: First Name : Last Name : Telephone : Relation to Patient : Drug or Food Allergies: Has the patient ever been hospitalized in the U.S? Yes No If yes, list U.S. hospitals with dates and reasons of hospitalization: Will an interpreter be needed to accompany patient during this medical visit? Yes No How did you first hear of the UAB Medical Center? Physician Former Patient/Friend Received Training at UAB Medical Publications Newspaper/News Latin American Representative Medical Conference Magazine Other (please, explain)
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