• The referral date and time.
  • Name of the health facility you are sending the woman.
  • Name, date of birth, ID number (if known) and address of the mother.
  • Relevant health history and your findings on physical examination or lab test.
  • Your suspected diagnosis.
  • Any treatment you have given to the mother.
  • Your reason for referring her.
  • Your name, date and signature.

Last modified: Tuesday, 21 February 2017, 4:10 PM