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Mubarak Hospital Psychiatry OUTPATIENT Referrals
This form must be filled in only by a doctor at Mubarak Hospital.
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Addiction Treament
Do not refer a patient for a primary diagnosis of addiction. Addiction treatment in Kuwait is centralized at the Addiction Treatment Hospital
Patient Information
Patient First Name
*
(in English)
Your answer
Patient Last Name
*
(in English)
Your answer
Gender
*
Male
Female
Age
*
in years
Your answer
Nationality
*
Kuwaiti
Non-Kuwaiti
File Number at Mubarak Hospital
*
Patients with no file at Mubarak can not be seen as we do not open new files at the psychiatry clinic
Your answer
Patient's phone number
*
IMPORTANT: This number will be called to give the appointment time. Make sure this is a number the patient will answer. Your can put more than one number by placing a comma between numbers.
Your answer
Clinical Information
Suspected Diagnosis
*
Choose
Anxiety Disorder
Attention Deficit Hyperactivity Disorder
Bipolar Disorder
Dementia
Depression
Eating Disorder
Obsessive Compulsive Disorder
Schizophrenia or other psychotic disorder
Sleep Disorder
Somatization Disorder
Post Traumatic Stress Disorder
Personality Disorder
Brief Patient History (Optional)
This helps triage appointments according to patient needs. Providing a short description is optional, but please do not expect a rapid triage of the patient if no description is provided.
Your answer
Referring Doctor Information
Referring Doctor
*
(in English)
Your answer
Unit
*
Choose
Medical Unit A
Medical Unit B
Medical Unit C
Medical Unit D
Medical Unit E
Cardiology
Diabetes
Endocrine
Gastroenterology
Geriatrics
Hematology
Neurology
Nephrology
Orthopedics
Respirology
Rheumatology
Surgery Unit A
Surgery Unit B
Surgery Unit C
Surgery Unit D
Urology
Vascular Surgery
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