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Child and Adolescent Psychiatry Consultation Form
Psychiatric Consultation Service for Patients up to 16 years old.
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date of admission *
MM
/
DD
/
YYYY
Nature of Request *
Please note: Urgent case submitted without calling the number shown, will be considered an elective case.  
Hospital Name *
Required
Ward *
Bed
Patient Name *
This form is not totally secured, please only submit first and second name, to maintain confidentiality.  
File Number *
Please state patient's file number.
Age in years *
Gender *
Positive past psychiatric history *
Current Medical Diagnosis *
Reason for Consult *
you can check multiple boxes
Required
Referring Dr Name *
Referring Dr Phone number *
Ward Phone number
Patient's Guradian or substitute decision maker consented for referral *
Given the sensitivity of mental illness; patient's guardian or substitute decision maker consent is required before our service can see the patient.
Required
contact information
Psychiatric Hospital Casualty direct no. 24841123
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