Referral Service Slip

POPCOM slip for referral service

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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