Transferring a Patient to Nakasero Hospital?  Complete the Form Below

    Select Department

    Appointment Notes

    Reason for referral/specific medical concern

    Patient Information:

    Patient Gender

    Patient Date of Birth

    Parent/guardian name* (if under 18 years of age

    Due to COVID-19, our specialists will conduct virtual visits when appropriate

    Does the patient need an interpreter?*

    Medical Records:
    Please upload referral medical records. If you are unable to upload files here, you can scan them to
    File types accepted: .pdf, .tif

    File 1

    File 2

    File 3

    Insurance Information:
    Does the patient have insurance?

    Referring Physician:

    Legal notice information:
    Confidentiality Notice: The information contained on this form may be confidential and legally privileged. It is intended only for use of the individual or entity named. If you are not the intended recipient, you are hereby notified that the disclosure, copying, distribution, or taking of any action in regards to the contents of this form – except its direct delivery to the intended recipient – is strictly prohibited. If you have received this form in error, please notify the sender immediately and destroy this form along with its contents, and delete from your system, if applicable