Referral Form Template

About This Tool

A standardized referral form template for frontline workers to use when referring children or pregnant/lactating mothers to health facilities. Ensures all critical information is captured and communicated effectively to the receiving facility.

Key Features

• Pre-printed format with all essential fields
• Sections for patient details, reason for referral, and observations
• Checklist format for common danger signs
• Space for referring worker's details and contact
• Counter-referral section for facility feedback
• Available as printable A5 format and digital fillable form

How to Use

1. 1Fill in the patient/beneficiary details completely
2. 2Check all applicable danger signs or reasons for referral
3. 3Add your observations and any actions already taken
4. 4Sign and add your contact details
5. 5Give the original to the patient, keep the carbon copy
6. 6Follow up with the facility within 24 hours
7. 7Record the referral in your monthly register