Autism Spectrum Disorder

Step1

The submitted referral will be reviewed during working days Sunday to Thursday, 9:00 to 14:00. If this is an emergency, please advise the patient to visit the nearest Emergency Department.

Please note that this referral is for Autism Spectrum Disorder (ASD) Assessment only.

Referring Physician Information

Patient Details

Parent/Guardian Details

Step2

Reason For Referral
Please check the most important items:
Significant Information:

Step3

Relevant History

List the medications the child is on or has been on previously (including Herbal medications, over the counter

Medication Dose Current?
Yes
Yes
Yes
Yes
Anything you’d like to add?
Comments:

Please attach any previous evaluations to this referral with the patient name clearly marked.

Al Jalila Children's Specialty Hospital

Al Jaddaf - Dubai United Arab Emirates

800 AJCH (8002524)