Transfer and Referral Record Form
UPDATED 2024
Transfer and Referral Record provides information to ensure that a resident has a safe and orderly transfer from your facility to another facility. Includes:
•Demographic information
•Diagnoses/Procedures
•Allergies: Drug and Food
•Medications
•Treatments
•Vaccinations - now includes COVID-19 vaccination status
•Assistance Needed
•Presence of Infection
•Vital Signs
•Verbal Communication of Information to the Receiving Facility
Size: 8 1/2" x 11"
Construction: 2-part carbonless
Paper: white original, yellow copy
Print: black ink
Packaging: 250 per pack