FUNDACION BEST A.C. FORMATO DE REFERENCIADATOS DEL PACIENTEFECHA DE REFERENCIA:___________________NOMBRE DEL PACIENTE: ________________________________________________________SEXO: __________ EDAD: ______________ DIAGNOSTICO: ____________________UNIDADA LA QUESEREFIERE:________________________________________________URGENCIA: SI ( )NO ( ) SERVICIO AL QUE SE REFIERE: _______________________DATOS DEL MEDICONOMBRE DEL MEDICO:_________________________________________________________CEDULA PROFESIONAL: ____________________ UNIVERSIDAD DE EGRESO: __________UNIDAD DE LA QUE REFIERE:___________________________________________________DIRECCION DEL CONSULTORIO: ________________________________________________RESUMEN CLINICO________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________DIAGNOSTICO DE REFERENCIA: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________TERAPEUTICA EMPLEADA: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________MOTIVO DE REFERENCIA: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________NOMBRE Y FIRMA DEL MEDICO