SULTAN AHMAD SHAH MEDICAL CENTRE @IIUM DEPARTMENT OF SHARIAH COMPLIANCE
REFERRAL FORM
Sultan Ahmad Shah Medical Centre @IIUM, Jalan Sultan Ahmad Shah, Bandar InderaMahkota, 25200 Kuantan, Pahang DarulMakmur.
Tel: 09-591 2500
DSCCN:
CASE STATUS:
Office use only
SASMEC-SHAR-F004 VER: 01 REV: 06 EFFECTIVE DATE:11 OCTOBER 2022
A. PATIENT/RELATIVE/STAFF INFORMATION Name
Address (if any)
Contact No. Gender
RN/ Staff No. NRIC (if any)
Clinic/ Ward/
Department/Unit Date
B. INFORMATION FROM DOCTOR IN-CHARGE/SUPERVISOR/REFERRER
Patient Diagnosis/ Current Condition of Referee:
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Type of case: Elective case Urgent case
C. PURPOSE
Please tick (√) the suitable box
Spiritual Care Support Practical support in Ibadah
Other. Please Specify: _________________________________________________
D. DETAILS
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Doctor/Staff/Supervisor Official Stamp:
Date:
