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Baseline Art Regimen Baseline labs (At ART Start) Baseline Clinical Status
Regimen: AZT-3TC-NVP Weight(Kg):
Current Art Regimen Most Recent Lab (if any) Current Clinical Status
Regimen: AZT-3TC-EFV CD4%: Weight(Kg):
WHO Stage:
Functional Status:
Drug Allergies:
Reasons for Transfer/Other relevant details:_____________________________________________________________________
________________________________________________________________________________________________________
Clinician's name:____________________________________Signature:_______________________________________________
Transfer Date:
Acknowledgement of transfer(To be completed by receiving Facility)
We acknowledge the transfer notice of Name:___________________Unique#:________________Date received:____/____/_____
Comments:_______________________________________________________________________________________________
________________________________________________________________________________________________________
Clinician's name:__________________________________________________Signature:_________________________________
Telephone:______________________________________________________________________Date:_____/_____/______