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Referral Form

Streamlined collaboration for complex case management.

Clinician at a workstation
Referral Form

A Structured Pathway for Complex Cases

Our referral pathway is designed to respect the clinician’s time while ensuring patient safety. This structured interface allows for the rapid transfer of critical data, facilitating a seamless transition of care from your clinic to our specialized infectious disease service.

  • Integrated Data Transfer: share culture reports (with AST), radiology, and previous antibiotic exposure.
  • Urgent Triage: flag sepsis, rapidly progressing infections, or immunocompromised states.
  • Direct Feedback Loop: consultant summary returned to the referring physician at the earliest.
Submit a Referral

Clinician Referral Form

All fields marked with * are required.

1. Referring Physician

2. Patient Information

3. Reason for Referral *

4. Urgency *

5. Clinical Summary

6. Attachments

Upload culture reports, AST sheets, imaging (DICOM/JPEG/PDF), or discharge summaries. You may attach multiple files.

Important: the combined size of all attached files must not exceed 20 MB. For larger files, please email them separately and reference this submission in the subject line.

7. Consent & Confirmation *

I confirm that the patient (or surrogate) has consented to this infectious-disease referral and the sharing of clinical data for consultation.

Submit to see which required fields still need attention.

Your referral will be sent securely to Dr. Shamily PB. A consultant summary will be returned to the referring physician at the earliest.
Your credentials will be saved confidentially.