{"id":808007,"date":"2025-08-21T14:05:30","date_gmt":"2025-08-21T10:05:30","guid":{"rendered":"https:\/\/ssmc.ae\/?page_id=808007"},"modified":"2025-08-21T14:05:30","modified_gmt":"2025-08-21T10:05:30","slug":"referral-patient-non-seha","status":"publish","type":"page","link":"https:\/\/ssmc.ae\/referral-patient-non-seha\/","title":{"rendered":"Referral Patient Non Seha"},"content":{"rendered":"<style>\r\nbody{\r\n    min-height: 100vh;\r\n    display: flex;\r\n    flex-direction: column;\r\n}\r\nfooter{\r\nheight:100%\r\n}\r\n<\/style>\r\n\r\n<form action=\"\" class=\"aaa-form aaa-referral-patient-form aaa-none-seha-form\" method=\"POST\" enctype=\"multipart\/form-data\"><input name=\"_nonce\" value=\"b866b3e3f2\" type=\"hidden\" \/><input name=\"_form_type\" value=\"none_seha_patient\" type=\"hidden\" \/><input name=\"_email_verified\" value=\"0\" type=\"hidden\" \/><div class=\"aaa-form-step step-1\"><div class=\"aaa-verify-field\"><div class=\"referral-account\"><div><h4>Don't have a referral account?<\/h4><small>Click on the button to register for a new account<\/small><\/div><br\/><a class=\"btn btn-primary\" href=\"\/referring-physician-registration\/\">Register a new account<\/a><\/div><hr\/><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-none_seha_code \" >\n    <label  for=\"none_seha_code\">Registered email address<span class=\"required\">*<\/span><\/label>    <input name=\"none_seha_code\" placeholder=\"Enter your email address...\" required=\"1\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-email-error\" id=\"email-error-message\"><\/div><div class=\"aaa-form-actions\"><button type=\"button\" class=\"btn btn-primary btn-verify-email\">Verify Email<\/button><\/div><\/div><\/div><style>.aaa-form-step.step-2{display:none!important}<\/style><div class=\"aaa-form-step step-2\"><div class=\"aaa-email-change-section\" style=\"text-align: center; margin-bottom: 20px; padding: 15px; background: #f8f9fa; border-radius: 8px; border: 1px solid #e9ecef;\"><small style=\"color: #6c757d; display: block; margin-bottom: 10px;\">Currently using email: <strong id=\"current-email-display\"><\/strong><\/small><button type=\"button\" class=\"btn btn-outline-secondary btn-sm\" onclick=\"NoneSehaReferral.changeEmail()\">Change Email Address<\/button><\/div><div class=\"aaa-section-nav\"><a href=\"#aaa-patient-data-section\" class=\"aaa-section-nav-item active\" onclick=\"scrollToSection('aaa-patient-data-section')\">\ud83d\udccb Patient Data<\/a><a href=\"#aaa-referral-details-section\" class=\"aaa-section-nav-item\" onclick=\"scrollToSection('aaa-referral-details-section')\">\ud83c\udfe5 Referral Details<\/a><a href=\"#aaa-medical-condition-section\" class=\"aaa-section-nav-item\" onclick=\"scrollToSection('aaa-medical-condition-section')\">\ud83d\udc8a Medical Condition<\/a><\/div><div class=\"aaa-form-section aaa-patient-data-section\" id=\"aaa-patient-data-section\" data-section-number=\"1\"><div class=\"aaa-section-header\"><h3>Section 1: Patient Data<\/h3><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-full_name \" >\n    <label  for=\"full_name\">Full Name<span class=\"required\">*<\/span><\/label>    <input name=\"full_name\" required=\"1\" placeholder=\"Enter patient's full name\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"full_name_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-date_of_birth \" >\n    <label  for=\"date_of_birth\">Date of Birth<span class=\"required\">*<\/span><\/label>    <input type=\"date\" name=\"date_of_birth\" required=\"1\" value=\"\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"date_of_birth_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-age \" >\n    <label  for=\"age\">Age<span class=\"required\">*<\/span><\/label>    <input type=\"number\" name=\"age\" required=\"1\" min=\"0\" max=\"150\" placeholder=\"Enter age\" value=\"\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"age_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"gender\">Gender<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"gender\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Gender<\/option>\n                            <option value=\"male\" >Male<\/option>\n                            <option value=\"female\" >Female<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"gender_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-emirates_id \" >\n    <label  for=\"emirates_id\">Emirates ID\/Passport No.<span class=\"required\">*<\/span><\/label>    <input name=\"emirates_id\" required=\"1\" placeholder=\"Enter Emirates ID or Passport number\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"emirates_id_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"emirates_id_file\">Emirates ID\/Passport Upload<span class=\"required\">*<\/span><\/label>    <input name=\"emirates_id_file\" accept=\".jpg,.jpeg,.png,.pdf\" required=\"1\" value=\"\" type=\"file\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"emirates_id_file_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-mrn_no \" >\n    <label  for=\"mrn_no\">MRN No<span class=\"required\">*<\/span><\/label>    <input name=\"mrn_no\" required=\"1\" placeholder=\"Enter Medical Record Number\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"mrn_no_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-referring_facility \" >\n    <label  for=\"referring_facility\">Referring Facility<span class=\"required\">*<\/span><\/label>    <input name=\"referring_facility\" required=\"1\" placeholder=\"Enter referring facility name\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"referring_facility_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"nationality\">Nationality<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"nationality\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Nationality<\/option>\n                            <option value=\"uae_national\" >UAE National<\/option>\n                            <option value=\"resident\" >Resident<\/option>\n                            <option value=\"visitor\" >Visitor<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"nationality_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-emergency_contact \" >\n    <label  for=\"emergency_contact\">Emergency Contact Number\/Next to Kin<span class=\"required\">*<\/span><\/label>    <input type=\"tel\" name=\"emergency_contact\" required=\"1\" placeholder=\"501413429 or +971501413429\" pattern=\"([0-9]{9}|\\+971[0-9]{9})\" maxlength=\"14\" value=\"\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"emergency_contact_validation\"><\/div><div class=\"phone-format-hint\">Accepted formats: 501413429 (9 digits) or +971501413429 (with country code)<\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"emergency_relationship\">Relationship with Emergency Contact<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"emergency_relationship\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Relationship<\/option>\n                            <option value=\"spouse\" >Spouse<\/option>\n                            <option value=\"parent\" >Parent<\/option>\n                            <option value=\"child\" >Child<\/option>\n                            <option value=\"sibling\" >Sibling<\/option>\n                            <option value=\"friend\" >Friend<\/option>\n                            <option value=\"other\" >Other<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"emergency_relationship_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-employer \" >\n    <label  for=\"employer\">Employer<span class=\"required\">*<\/span><\/label>    <input name=\"employer\" required=\"1\" placeholder=\"Enter employer name or &quot;Unemployed&quot;\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"employer_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-insurance_provider \" >\n    <label  for=\"insurance_provider\">Insurance Provider<span class=\"required\">*<\/span><\/label>    <input name=\"insurance_provider\" required=\"1\" placeholder=\"Enter insurance provider name or &quot;Self-pay&quot;\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"insurance_provider_validation\"><\/div><\/div><div class=\"aaa-form-section aaa-referral-details-section\" id=\"aaa-referral-details-section\" data-section-number=\"2\"><div class=\"aaa-section-header\"><h3>Section 2: Referral Details & Diagnosis<\/h3><p>Please provide detailed information about the referral and patient diagnosis.<\/p><\/div><div class=\"aaa-form-group required\"><div class=\"control-group control-group-text control-group-referral_datetime \" >\n    <label  for=\"referral_datetime\">Referral Date\/Time<span class=\"required\">*<\/span><\/label>    <input type=\"datetime-local\" name=\"referral_datetime\" required=\"1\" value=\"\" \/>\n<\/div><\/div><div class=\"validation-message\" id=\"referral_datetime_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"reason_for_transfer\">Reason for Transfer<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"reason_for_transfer\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Reason<\/option>\n                            <option value=\"specialized_care\" >Need for Specialized Care<\/option>\n                            <option value=\"patient_family_request\" >Patient or Family Request<\/option>\n                            <option value=\"facility_limitations\" >Facility Limitations<\/option>\n                            <option value=\"specialist_consultation\" >Specialist Consultation Required<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"reason_for_transfer_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"primary_diagnosis\">Primary Diagnosis<span class=\"required\">*<\/span><\/label>    <textarea name=\"primary_diagnosis\" required=\"1\" placeholder=\"Please describe the primary diagnosis in detail...\" rows=\"4\" type=\"textarea\"><\/textarea>\n<\/div><\/div><div class=\"validation-message\" id=\"primary_diagnosis_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"service_available\">Is the service requested available at your facility?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"service_available\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"service_available_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"police_case\">Police Case?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"police_case\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"police_case_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"mva_case\">Motor Vehicle Accident (MVA)?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"mva_case\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"mva_case_validation\"><\/div><div class=\"aaa-form-group required\"><div class=\"control-group\">\n    <label  for=\"recent_admission\">Admission within last 6 months to hospital?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"recent_admission\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"validation-message\" id=\"recent_admission_validation\"><\/div><\/div><div class=\"aaa-form-section aaa-medical-assessment-section\" id=\"aaa-medical-assessment-section\" data-section-number=\"3\"><div class=\"aaa-section-header\"><h3>Section 3: Medical Assessment & Clinical Details<\/h3><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"treatment_abroad\">Treatment abroad in last 6 months?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"treatment_abroad\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><div class=\"control-group\">\n    <label  for=\"war_victim\">Victim or war, gunshot, or blast?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"war_victim\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"mdro_colonized\">Colonized with MDROs (Carbapenem resistant Organisms, MRSA, VRE, or ESBL)?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"mdro_colonized\" required=\"1\" onclick=\"jQuery(this).val() == &quot;yes&quot; ? jQuery(&quot;.control-group-organism_type&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-organism_type&quot;).addClass(&quot;hidden&quot;)\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-organism_type hidden\" >\n    <label  for=\"organism_type\">Type of Organisms<\/label>    <input name=\"organism_type\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"candida_auris\">Colonized with Candid auris?<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"candida_auris\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select<\/option>\n                            <option value=\"yes\" >Yes<\/option>\n                            <option value=\"no\" >No<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"clinical_urgency\">Clinical Urgency for transfer<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"clinical_urgency\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Urgency Level<\/option>\n                            <option value=\"level_0\" >Level 0: Emergency (Resuscitation, Immediate)<\/option>\n                            <option value=\"level_1\" >Level 1: Critical(<3hrs.)<\/option>\n                            <option value=\"level_2\" >Level 2: Very Urgent (<6 hrs.)<\/option>\n                            <option value=\"level_3\" >Level 3: Urgent (<24 hrs.)<\/option>\n                            <option value=\"level_4\" >Level 4: Elective\/Scheduled<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><\/div><div class=\"aaa-form-section aaa-medical-condition-section\" id=\"aaa-medical-condition-section\" data-section-number=\"3\"><div class=\"aaa-section-header\"><h3>Section 3: Patient Medical Condition<\/h3><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"current_location\">Current Location<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"current_location\" required=\"1\" onclick=\"jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-current_location_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-current_location_other&quot;).addClass(&quot;hidden&quot;)\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Location<\/option>\n                            <option value=\"ed\" >ED<\/option>\n                            <option value=\"general_ward\" >General Ward<\/option>\n                            <option value=\"critical_care\" >Critical Care Bed<\/option>\n                            <option value=\"hdu\" >HDU<\/option>\n                            <option value=\"other\" >Other<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-current_location_other hidden\" >\n    <label  for=\"current_location_other\">Other Location<\/label>    <input name=\"current_location_other\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"airway_support\">Airway Support<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"airway_support\" required=\"1\" onclick=\"jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-airway_support_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-airway_support_other&quot;).addClass(&quot;hidden&quot;)\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Airway Support<\/option>\n                            <option value=\"room_air\" >Room Air (RA)<\/option>\n                            <option value=\"ventilated\" >Ventilated<\/option>\n                            <option value=\"bipap\" >BIPAP<\/option>\n                            <option value=\"cpap\" >CPAP<\/option>\n                            <option value=\"high_flow\" >High Flow<\/option>\n                            <option value=\"home_ventilation\" >Home Ventilation<\/option>\n                            <option value=\"other\" >Other<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-airway_support_other hidden\" >\n    <label  for=\"airway_support_other\">Other Airway Support<\/label>    <input name=\"airway_support_other\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"circulation_support\">Circulation Support<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"circulation_support\" required=\"1\" onclick=\"jQuery(this).val() == &quot;other&quot; ? jQuery(&quot;.control-group-circulation_support_other&quot;).removeClass(&quot;hidden&quot;):jQuery(&quot;.control-group-circulation_support_other&quot;).addClass(&quot;hidden&quot;)\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Circulation Support<\/option>\n                            <option value=\"iv_fluids\" >IV Fluids<\/option>\n                            <option value=\"inotropes\" >Intropes or Vasopressors<\/option>\n                            <option value=\"insulin\" >Insulin Infusion<\/option>\n                            <option value=\"high_alert\" >Other High Alert Medications<\/option>\n                            <option value=\"other\" >Other<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-circulation_support_other hidden\" >\n    <label  for=\"circulation_support_other\">Other Circulation Support<\/label>    <input name=\"circulation_support_other\" value=\"\" type=\"text\" \/>\n<\/div><\/div><h4>Vital Signs<\/h4><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-blood_pressure \" >\n    <label  for=\"blood_pressure\">Blood Pressure (BP)<span class=\"required\">*<\/span><\/label>    <input name=\"blood_pressure\" required=\"1\" placeholder=\"e.g., 120\/80\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-heart_rate \" >\n    <label  for=\"heart_rate\">Heart Rate (HR)<span class=\"required\">*<\/span><\/label>    <input name=\"heart_rate\" required=\"1\" placeholder=\"e.g., 72\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-respiratory_rate \" >\n    <label  for=\"respiratory_rate\">Respiratory Rate (RR)<span class=\"required\">*<\/span><\/label>    <input name=\"respiratory_rate\" required=\"1\" placeholder=\"e.g., 18\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-oxygen_saturation \" >\n    <label  for=\"oxygen_saturation\">Oxygen Saturation (Sat O2)<span class=\"required\">*<\/span><\/label>    <input name=\"oxygen_saturation\" required=\"1\" placeholder=\"e.g., 98%\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-temperature \" >\n    <label  for=\"temperature\">Temperature<span class=\"required\">*<\/span><\/label>    <input name=\"temperature\" required=\"1\" placeholder=\"e.g., 37.2&deg;C\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-gcs \" >\n    <label  for=\"gcs\">GCS<span class=\"required\">*<\/span><\/label>    <input name=\"gcs\" required=\"1\" placeholder=\"e.g., 15\/15\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-intubated_tracheostomy \" >\n    <label  for=\"intubated_tracheostomy\">Intubated\/Tracheostomy<span class=\"required\">*<\/span><\/label>    <input name=\"intubated_tracheostomy\" required=\"1\" value=\"\" type=\"text\" \/>\n<\/div><\/div><div class=\"aaa-form-group\"><div class=\"control-group control-group-text control-group-referring_hospital \" >\n    <label  for=\"referring_hospital\">Referring Hospital<span class=\"required\">*<\/span><\/label>    <input name=\"referring_hospital\" required=\"1\" value=\"\" type=\"text\" \/>\n<\/div><div class=\"control-group control-group-text control-group-nursing_contact \" >\n    <label  for=\"nursing_contact\">Referring Nursing supervisor or Referral Centre contact No<span class=\"required\">*<\/span><\/label>    <input type=\"tel\" name=\"nursing_contact\" required=\"1\" placeholder=\"501413429 or +971501413429\" pattern=\"([0-9]{9}|\\+971[0-9]{9})\" maxlength=\"14\" value=\"\" \/>\n<\/div><\/div><div class=\"phone-format-hint\">Accepted formats: 501413429 (9 digits) or +971501413429 (with country code)<\/div><div class=\"aaa-form-group\"><div class=\"control-group\">\n    <label  for=\"emirates\">Emirates<span class=\"required\">*<\/span><\/label>    <div class=\"select-wrap\">\n        <select name=\"emirates\" required=\"1\" type=\"text\">\n                            <option value=\"\" selected=\"selected\">Select Emirates<\/option>\n                            <option value=\"abu_dhabi\" >Abu Dhabi<\/option>\n                            <option value=\"dubai\" >Dubai<\/option>\n                            <option value=\"sharjah\" >Sharjah<\/option>\n                            <option value=\"ajman\" >Ajman<\/option>\n                            <option value=\"fujairah\" >Fujairah<\/option>\n                            <option value=\"ras_al_khaimah\" >Ras Al Khaimah<\/option>\n                            <option value=\"umm_al_quwain\" >Umm Al Quwain<\/option>\n                    <\/select>\n    <\/div>\n<\/div><\/div><hr\/>The information you send will be uploaded to the patient's medical record.<\/div><hr\/><small>Fields marked with (*) are mandatory<\/small><div class=\"aaa-form-section aaa-submission-section\"><div class=\"aaa-form-actions\"><div class=\"aaa-navigation-buttons\"><button type=\"button\" class=\"btn btn-secondary btn-prev-section\" onclick=\"scrollToSection('aaa-patient-data-section')\">\u2190 Previous Section<\/button><button type=\"button\" class=\"btn btn-info btn-review-form\" onclick=\"reviewForm()\">Review Form<\/button><button class=\"btn btn-primary btn-submit-referral\" type=\"submit\">\n    Submit Patient Referral<\/button><\/div><\/div><\/div><\/div><\/div><input name=\"_referral_form\" value=\"patient-form\" type=\"hidden\" \/><\/form>","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"pages\/page-referralform.php","meta":{"inline_featured_image":false},"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v19.3 - https:\/\/yoast.com\/wordpress\/plugins\/seo\/ -->\n<title>Referral Patient Non Seha &ndash; Sheikh Shakhbout Medical City Abu Dhabi<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" 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