Referral Procedures

Al Jalila Children’s is a specialty hospital; therefore all our patients have to be referred by a general paediatrician or a family practitioner. Our patients are aged from 0 to 16 years and require parent support throughout the patient journey. All doctors should provide the Appointment Centre with sufficient information about the patient so that the referral can be made quickly and correctly. All referrals from doctors can be dealt with directly by the Appointment Centre. There are different types of referrals. The following can be catered for at this stage:
  • Simple request for a specific specialty
  • General paediatricians for under 12 year and over 12 year old patients
  • Neurosciences Centre of Excellence
  • Child and Adolescent Mental Health Centre of Excellence

Referral Procedures

For outpatient department referrals,  kindly fill the respective referral form here and email it to us. For PICU, NICU, and CICU referrals, please fill the form here.

Refer a Patient

To refer your patient for an appointment with one of our doctors, please complete an online request using the form below. Once we receive your request, we will contact your patient directly within 24 hours to schedule their appointment.

Your Name
Contact
Find Doctor
When
Reason for visit

Referral Forms

For referrals to Al Jalila Children's, kindly fill in the respective form and email it to us. Our Case Management team will get in touch with you soon. Kindly note to attach copies of patient's Emirates ID and insurance to enable us to verify and proceed with a referral.

Form Name
Download File
Sent to

Diagnostic Imaging Department Outpatient Order Form

NICU Referral Form

Mental Health and Psychology

Neurodevelopmental

Electro Neuro Diagnostic Study

Speciality Services

Sleep Study Referral Form

Step 1

PATIENT NAME:

DOB:

SEX:

MaleFemale

INTERPRETER NEEDED:

YesNo, IF YES, PREFERRED LANGUAGE:

PARENT/GUARDIAN CONTACT

PARENT/GUARDIAN NAME:

HOME PHONE:

MOBILE PHONE:

ADDRESS:

CITY:

REFERRING PHYSICIAN CONTACT

REFERRING PHYSICIAN NAME:

CLINIC/HOSPITAL NAME:

WORK PHONE:

MOBILE:

DIAGNOSIS:

Step 2

HEALTH INSURANCE INFORMATION
INSURANCE COMPANY:

INSURANCE ID:

PLEASE PROVIDE A COPY OF INSURANCE CARD, FRONT AND REAR, TOGETHER WITH PROGRESS NOTES
FOR AUTHORIZATION PURPOSES

INSTRUCTION FOR STUDY
Baseline Sleep StudyCPAP/BIPAP TitrationSplit Night StudyOvernight Oximetry

Would you like the patient to be seen at the Paediatric Sleep Clinic prior to the sleep study?
YesNo

Step3

SLEEP HISTORY
DOES, OR HAS, THE PATIENT:

Snore excessively more than 3 nights a week? YesNo
Been observed to stop breathing or have pauses in breathing during sleep? YesNo
Awaken with gasping, choking, dry mouth or throat? YesNo
Tend to be a mouth breather? YesNo
Occasionally wets the bed (for children 3 and older)? YesNo
Feel sleepy or fatigued during the day? YesNo
Have poor school performance? YesNo
Have hyperactivity or is inattentive? YesNo
Suffers from morning headaches? YesNo
Experience a restless sensation in arms or legs during sleep or in the evening? YesNo
Been told that they make kicking movements during sleep: YesNo
Have difficulty falling asleep at the beginning of the night? YesNo
Have difficulty staying awake during the day? YesNo
Have sudden loss of strength in arms or legs while awake? (Induced by strong emotion) YesNo
Had a previous sleep study? YesNo
If so, when and where? YesNo
How long does it typically take the patient to fall asleep? YesNo
Usual Bedtime:

PM

Usual wake-up time:

AM

Step4

MEDICAL HISTORY

AsthmaEnlarge tonsilsDeviated septumGastroesophogeal RefluxAllergiesEnlarged adenoidsNasal obstructionCraniofacial MalformationObesityPrevious T&A?Enlarged TongueSeizuresCardiac problemsNasal polypsDiabetesOther Medical History/Allergies:

Medications:

I AUTHORIZE LAB TO PERFORM SLEEP STUDIES ON ABOVE PATIENT ACCORDING TO THEIR
PROTOCOLS, INCLUDING URGENT INITIATION OF O2 & CPAP

PHYSICIAN:

DATE:


Sleep Clinic Referral Form

Step 1

PATIENT NAME:

DOB:

SEX:

MaleFemale

INTERPRETER NEEDED:

YesNo, IF YES, PREFERRED LANGUAGE:

PARENT/GUARDIAN CONTACT

PARENT/GUARDIAN NAME:

HOME PHONE:

MOBILE PHONE:

ADDRESS:

CITY:

REFERRING PHYSICIAN CONTACT

REFERRING PHYSICIAN NAME:

CLINIC/HOSPITAL NAME:

WORK PHONE:

MOBILE:

DIAGNOSIS:

Step 2

HEALTH INSURANCE INFORMATION
INSURANCE COMPANY:

INSURANCE ID:


PLEASE PROVIDE A COPY OF INSURANCE CARD, FRONT AND REAR, TOGETHER WITH PROGRESS NOTES
FOR AUTHORIZATION PURPOSES

Step3

SLEEP HISTORY
DOES, OR HAS, THE PATIENT:

Snore excessively more than 3 nights a week? YesNo
Been observed to stop breathing or have pauses in breathing during sleep? YesNo
Awaken with gasping, choking, dry mouth or throat? YesNo
Tend to be a mouth breather? YesNo
Occasionally wets the bed (for children 3 and older)? YesNo
Feel sleepy or fatigued during the day? YesNo
Have poor school performance? YesNo
Have hyperactivity or is inattentive? YesNo
Suffers from morning headaches? YesNo
Experience a restless sensation in arms or legs during sleep or in the evening? YesNo
Been told that they make kicking movements during sleep: YesNo
Have difficulty falling asleep at the beginning of the night? YesNo
Have difficulty staying awake during the day? YesNo
Have sudden loss of strength in arms or legs while awake? (Induced by strong emotion) YesNo
Had a previous sleep study? YesNo
If so, when and where? YesNo
How long does it typically take the patient to fall asleep? YesNo
Usual Bedtime:

PM

Usual wake-up time:

AM

Step4

MEDICAL HISTORY

AsthmaEnlarge tonsilsDeviated septumGastroesophogeal RefluxAllergiesEnlarged adenoidsNasal obstructionCraniofacial MalformationObesityPrevious T&A?Enlarged TongueSeizuresCardiac problemsNasal polypsDiabetesOther Medical History/Allergies:

Medications:

I AUTHORIZE LAB TO PERFORM SLEEP STUDIES ON ABOVE PATIENT ACCORDING TO THEIR
PROTOCOLS, INCLUDING URGENT INITIATION OF O2 & CPAP

PHYSICIAN:

DATE:


Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai United Arab Emirates

800 AJCH (8002524)

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