Document for referral patient.
Providing referral in a primary care setting
What should a referral within or outside the state look like?

Referral Order
Sample

Authorizing provider:	Asif Qrueshi, MD
Signing provider:	Asif Qrueshi, MD
Telephone:	(773) 561-6102
Fax:	(773) 337-9107
Service provider:	King Fahed Hospital Medina al munawara counseling and psychiatry services
Service provider telephone:
Service provider fax:
Patient details
Address of patient:	Sabha Masajid, Medina Al Munarawa, SA, Asia
Name of patient:	Zakia
Date of birth of patient:	Not known
Patient number:	Not known
Age of patient:	Approximately 35 to 45 years old
Any other relevant number:
Gender:	Female
Preferred language:	Arabic/English
Diagnosis of Zakia in Medina Al Munawara:	Deprivation of rights under the color of law Stress Abuse Women’s rights violation
Recommendations:	Recommendations should be relevant to food, clothing, housing, healthcare, transportation, security, education, or any issues an individual is having that depend on the requirement or situation. Doctor Asif Qureshi recommends counseling due to oppression. Should be slowly connected to Doctor Asif Qureshi.

One copy remains in the computer systems of the state healthcare organization. One copy must be given to the patient. When were these resources last updated? These resources were last updated on February 10, 2016.