Refer a Patient: Form for Specialized Physician Matching

RAP_Patient_Info_Headline

Please ensure to include in the mandatory medical report the justification for this imaging service.

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 to include in the mandatory medical report the justification for this imaging service.

Relevant X-ray Report *

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