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Forms for doctors

These forms are for use by medical practitioners in Malta only. Unauthorised use can lead to prosecution under the relevant ordinance or legislation.

​myHEALTH
Used by patients to give doctors consent to access their data through myHealth. The doctor has to witness the patient's signature and sign the form before submission to the myHealth office.

REFERRALS TO HOSPITAL

Ticket of referral to the A & E Department (Form DH22B) (DH circ 137/2011)
Used to refer a patient to the Accident & Emergency Department of a Government hospital.  Both sides have to be printed.

Used to refer a patient for an outpatient a​ppointment at Mater Dei Hospital or Health Centre clinics.  The doctor needs to log on using his/her e-ID to access this form. For more information email bookingoffice.mdh@gov.mt​.

Ticket of Referral (offline PDF form - general referral form for Government hospitals and Health Centres)​

Gender Wellbeing Clinic
The following methods of referral may be used to refer persons to the Gender Wellbeing Clinic:
Gender Wellbeing Clinic Electronic Referral Form - medical doctors, psychologists and social workers who work in the public sector can access the electronic referral system by sending an email to transhealthcare.health@gov.mt
Gender Wellbeing Clinic Referral Ticket​ - the referral ticket can be scanned and e-mailed to transhealthcare.health@gov.mt or else delivered by hand to Mater Dei Hospital reception.​


Cancer fast-tracking forms (available only to family doctors participating in the relevant schemes)


REFERRALS FOR INVESTIGATION


Used by private family doctors to refer a patient to a health centre for radiological investigation. For more information, contact the Primary Health Care Department. Used in conjunction with the Radiation Protection 118 - Referral Guidelines for Imaging​ to ensure and document that the medical exposure of the patient is warranted based on the medical indications.

Used to request a bone density study.  The PDF form should be filled in completely, printed, signed and sent by post for appointment to the Bone Density Unit at Mater Dei Hospital. For further information please refer to DH circular 278/2013 and/or send an email to bonedensity.mdh@gov.mt.

SCHEDULE V FORMS

Schedule V Application Form
Form POYC16

Issued with DH Circular 98/2019

CERTIFICATES AND NOTIFICATIONS

Used to notify statutory immunisations to the public health authorities. The doctor needs to log on using his/her e-ID to access this form. For more information email immunisation@gov.mt.

Death Certificate (Form DH35)
Used to certify death and its cause. This PDF v​ersion may be completed online and then printed and signed. For more information contact the National Mortality Registry at the Department of Health Information & Research.

Used to apply for a new or renewed Control Card. For more information contact the Drug Control Unit at the Department of Environmental Health.

Used for Maltese residents who want to travel to another Schengen state and who need to take a narcotic drug and/or psychotropic substance during this period. Both sides have to be printed. Valid only for 30 days. Medical practitioners are to fill in sections A, B and C only whilst subsequently Section D is to be authenticated by the Drug Control Unit at 12, City Gate Shopping Arcade, Valletta.

Used to notify a new case of cancer. For more information, contact the National Cancer Registry at the Department of Health Information & Research.

Used to notify a new case of notifiable infectious disease. For more information, contact the Infectious Disease Prevention and Control Unit.


MENTAL HEALTH ACT FORMS

Application to restrict Freedom of Communication.

Application for a person to be admitted involuntarily for Treatment Order.

Application for extension of involuntary admission for Treatment Order.

Application for a continuing Detention Order.

Application for release from Involuntary Admission for Treatment Order / continuing Detention Order.

Application for a person to be placed on a Community Treatment Order.

Notification of agreement to give Medical Care in the Community.

Conveyance Order by the responsible Specialist to take a patient for Assessment and / or Treatment.

Conveyance Order by the Minister responsible for Justice to take a patient for Assessment and / or Treatment.

Application for Revocation of a Community Treatment Order.

Certification of Lack of Mental Capacity.

Application for Revocation of a Certificate of lack of Mental Capacity.

Special Treatment List.

Application for Invasive or Irreversible Treatment.

Application for Leave under Article 37 for a person detained under Court Order.

Applications for admission to Mount Carmel Hospital
Application for a person to be admitted involuntarily for observation in a licensed Mental Health Facility.

Notification by specialist with clinical experience ​of working with minors with Mental Health problems for an involuntary admission for observation of a minor​.​

​A reader for PDF forms may be downloaded for free from http://www.adobe.com/products/acrobat/readstep2.html​