Step1

Please Note: In order for AJCH to efficiently manage your referral, this form must be fully completed and along with all requested documentation. All referrals will be dealt with between the hours of 09:00 -14:00 Sun- Thurs.

Referring Physician Details
Requested Speciality:*

Patient Details

Parent/Guardian Details

Step2

Reason For Referral
Please check the most important items:
Significant Information:

Step3

Relevant History

List the medications the child is on or has been on previously (including Herbal medications, over the counter

Medication Dose Current?
Yes
Yes
Yes
Yes

Please attach any previous evaluations to this referral with the patient name clearly marked.

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai United Arab Emirates

800 AJCH (8002524)