Online Patient Referral

As a referring Physician, please follow the below procedures:

Inform the patient or the patient's family regarding the referral prior to any arrangements being made. Complete the online form below.
Attach the needed documents, copied materials and investigations.
Once we received the below information, our referral coordinators will complete the referral process for you.Our specialist at Zulekha Hospital will communicate directly with you, keeping you apprised of the patient's condition, treatment and outcome.

This form should be filled out by the referring Physician.

Name*

Nationality*

Patient Contact Number *

Insurance Company
Current Medications the patient is using
Age*

Gender

Does the patient have residence visa in UAE? Yes No

History & Diagnosis*

Referring Medical Professionals Information

Hospital Name*

Referring Physician Email*

Referring Physician Mobile*

Referring Physician Name*

Referring Physician Speciality*

Referring Hospital/Clinic Fax*

Speciality

Attach the needed documents

Specialist Name

Select Documents (can attach more than one file)

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