Refer a Patient: Form for Specialized Physician Matching

RAP_Patient_Info_Headline

Please ensure that the following information is provided exactly as it
appears on the patient's Emirates ID or passport.

Patient First Name *

Patient Family/Last Name *

Date of Birth *

Patient Email Address

Patient Phone Number *

Emirates ID *

Emirates ID of Patient

Emirates ID of Patient *

Note: Copy of patient’s Emirates ID is MANDATORY for Imaging Services referral request

Does the patient have any relevant X-ray completed in the last 6 months? *

Yes

Please ensure that the following information is provided exactly as it appears on the patient's Emirates ID or passport.

Please ensure that the following information is provided exactly as it
appears on the patient's Emirates ID or passport.

Relevant X-ray Report *

Note: Copy of patient’s Emirates ID is MANDATORY for Imaging Services referral request

Medical Report of Patient

Medical Report of Patient *

Note: Copy of patient’s latest medical report is MANDATORY for Imaging Services referral request

Claim Form

Note: For patients under NAS insurance, claim form with physician’s signature and stamp is required.

Do you require a physician report? *

Yes

Medical Records Department Email Address *

Note: Please note that the patient's report will be sent to your HIMS department to scan in the patient's file.

Refer a Patient