Exchange Doctor/Department
X
Hospital No :
{{SelectedVisit.PatientCode}}
Patient Name :
{{SelectedVisit.ShortName}}
Age/Sex : {{SelectedVisit.Age}}/ {{SelectedVisit.Gender[0]}}
Address :
{{SelectedVisit.Address}}
Contact No :
{{SelectedVisit.PhoneNumber}}
Registration Date/Time
:
Registered Department
:
Assigned Doctor
:
Exchanged Department
*
:
Exchanged Department is Required
Exchanged Doctor
*
:
Exchanged Doctor is Required
Reason to Exchange
: