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REFER PATIENT

The Royal Phnom Penh Hospital Referral Center is open 24-hours daily to coordinate the referral patients to Royal Phnom Penh Hospital. The center can help you access our doctors and medical team. We evaluate the needs of each patient to ensure that appropriate care is provided.

Once the hospital admission has been scheduled, our Referral Coordinators will complete the process of coordinating the referral for you. The specialist will communicate directly with you, keeping you apprised of the patient’s condition, treatment and outcome.

When your patient is discharged, our Referral Center will facilitate the transfer of your patient back to your hospital or practice.

Medical Referral Form

Personal Information
Patient First Name:
Patient Last Name:
Gender:
Marital Status:
Date of Birth:
Occupation:
Address:
Nationality:
Passport Number:
Languages Spoken:
Hospital Number:
Contact Phone:
Contact Mobile:
Email:
Emergency Contact Details:
Relationship with Patient:
Do you have Medical Insurance: NoYes
If yes,Insurance Company name:
Policy Number:
Do you require an Interpreter: NoYes
If yes, Language Required:
Do you require Visa Assistance: NoYes
If yes, Please provide a copy of your passport, RPPH appointment letter and Medical Diagnosis.
Clinical Information
Medical Diagnosis:
Current Medical Condition: Please advise if patient clinical condition is unstable or likely to deteriorate
Medical List:
Do you have any allergy: NoYes
If yes, please provide details:
Treatment Given:
Reason for Referral:
Special Needs:
Prepared By: