Patient Referral Form:

Kindly complete all requested fields in full. Information is required to submit pre-authorisation request from medical schemes

PATIENT INFORMATION (or STICKER)

Patient Name:

Patient ID Number:

Patient Email:

Patient Cellphone Number:

Patient Medical Aid:

Patient Medical Aid Number:

Patient Medical Aid Option:

Patient Address:

ICD10 Code(s):

NEXT OF KIN DETAILS

Patient Next of Kin Contact Name:

Patient Next of Kin Contact Number:

Service Option:

Remote Patient Monitoring (RPM) service: The patient receives: Continuous remote vital signs monitoring • Daily virtual visits • Clinical team available 24/7 at our clinical command centre • Rapid response protocols • Short-term homeoxygen (as required). Hospital at home (HAH) service: The patient receives: ALL of the above AND • in-person clinical home visits by a member of our healthcare team for 3 days • Medication administration • Access to pathology laboratory services • Allied health services, including physiotherapy (if required).

Referring Doctor Virtual Oversight:

Please note: Only doctors who opt-in are reimbursed for continuing to provide virtual clinical oversight for their patients Virtual Clinical Oversight (Opt-in doctors only): Doctors are invited to provide virtual clinical oversight for their patients for the duration of their patient’s admission to Quro Medical. As the treating doctor, you remain ultimately responsible for the patient’s clinical management. We ask that you remain engaged in the care of your patient through the Quro Medical Insight platform (https://insight.quromedical.com/).

KEY REFERRAL INFORMATION

Indication for admission to Quro:

Clinical Findings & Investigations:

Baseline Vitals (please attach copies of results):

Care Plan:

Current Chronic Medication (include all medication and dosages):

PRESCRIPTION (ACUTE MEDICATION)

Doctor's Name:

Doctor's Email:

Doctor's Practice Number:

Doctor's Cellphone Number:

General inquiries: +27 (0) 10 824-1150 Referral inquiries: 010 141 7715

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