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Referral Service Slip
POPCOM slip for referral service
Your Browser Doesn't Support Canvas. Showing the Text Content of the PDF Instead: Annex 5. Referral and Service Slip
SERVICE SLIP
REFERRAL SLIP
Date: ________________________
Date of visit: _________________
(NOTE: Please return this to the Couples or to the Community Volunteer)
Name of Client:
Name of Client:
Address of Client:
Address of Client:
Note: THIS PORTION IS FOR SERVICE PROVIDER
Instruction: PLEASE CHECK APPROPRIATE OPTIONS BELOW
Please check Family Planning services provided to the client:
1. Expressing intention to use FP with the method below:
NFP Method
Check
SDM
LAM
CMM
STM
Artificial
Method
Permanent
Method
Check
Pills
IUD
Injectable
Condom
Implant
Ligation
Vasectomy
2. Wants FP but undecided on what method to use (
3. Undecided, need further counseling (
1. FP Method
)
)
Check
NFP Method
Check
SDM
LAM
CMM
STM
Artificial
Method
Check
Pills
IUD
Injectable
Condom
Implant
2. Counseling (
Check
Permanent Method
Ligation
Vasectomy
)
3. Other concerns:
Client not provided FP service because of the following reason/s:
4. User of Traditional method (please specify method used):
1. Needed FP method is not available in the facility
NOTE: This portion is for COMMUNITY VOLUNTEER
2. No service provider available during the visit
( )
3. No trained personnel to do the needed FP service ( )
4. Client is not qualified to use preferred method,
Client is referred to:
Name of Health Service Facility (BHS, RHU, Hospital) __________________________
Address of Health Service Facility : _________________________________________
Community Volunteer (BSPO/BPV, BHW, BNS, etc.) who referred the client:
(
)
counseled to use _______________________ but client is undecided (
)
5. Other reasons, please specify: ___________________________________
ACTION NEEDED :
1. Client has been provided a method (
)
Date of accepting the method: _______________________
2. Client is advised to go to : ________________________
Name & address of referral facility: ____________________________________
Name and Signature
Name, Position and Signature of attending Health Service Provider
