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

myHealth doctor-patient link consent form
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.

Online Ticket of Referral to Mater Dei Hospital or Health Centre Clinics
Used to refer a patient for an outpatient appointment 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 Electronic Referral Form
Referrals to the Gender Wellbeing Clinic can be made through a GP, nurse, psychologist / counsellor or social worker and then submit it via e-mail on transhealthcare.health@gov.mt. One may opt to fill in the Gender Wellbeing Clinic referral form online.

Referral to Early Arthritis Clinic at Mater Dei Hospital

Cancer Fast-Track System
The cancer fast-track system is available to the following services:

  • Colon Cancer Fast-Track.
  • Respiratory Cancer Fast-Track.
  • Breast Cancer Fast-Track.
  • Haematology Cancer Fast-Track.
  • Prostate Cancer Fast-Track.
  • Upper GI Cancer Fast-Track.
  • Head and Neck Cancer Fast-Track.
  • Skin Cancer Fast-Track.

Referrals for Investigation

Referral to Pathology Department at Mater Dei Hospital

Radiology Request by Private Family Doctor
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.

Referral to MDH for Bone Density Study
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.

Benign Prostatic Enlargement Schedule V Medication Form
(Original version was issued with DH Circular 98/2019).

Certificates and Notifications

Online Immunisation Report
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 version may be completed online and then printed and signed. For more information contact the National Mortality Registry at the Department of Health Information & Research.

Request For The Issue/Renewal of a Control Card For Narcotic And Psychotropic Drugs
Used to apply for a new or renewed Control Card. For more information contact the Drug Control Unit at the Department of Environmental Health.

Notification to SPH of Urgent Prescription (requires e-ID login)
Used to notify the Superintendent of Public Health when an urgent prescription for dangerous drugs has been issued without use of the Control Card for these types of drugs. Offline alternative: PDF

Schengen Medical Certificate
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.

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

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

Injury on Duty GP75 NI30 page 4

Mental Health Act Forms

Schedule 1
Application to restrict Freedom of Communication.

Schedule 2
Application for a person to be admitted involuntarily for observation in a Licensed Mental Health Facility.

Schedule 3
Application for a person to be admitted involuntarily for Treatment Order.

Schedule 4
Application for extension of involuntary admission for Treatment Order.

Schedule 5
Application for a continuing Detention Order.

Schedule 6
Application for release from Involuntary Admission for Treatment Order / continuing Detention Order.

Schedule 7
Application for a person to be placed on a Community Treatment Order.

Schedule 8
Notification of agreement to give Medical Care in the Community.

Schedule 9 – Part I
Conveyance Order by the responsible Specialist to take a patient for Assessment and / or Treatment.

Schedule 9 – Part II
Conveyance Order by the Minister responsible for Justice to take a patient for Assessment and / or Treatment.

Schedule 10
Application for Revocation of a Community Treatment Order.

Schedule 11
Certification of Lack of Mental Capacity.

Schedule 12
Application for Revocation of a Certificate of lack of Mental Capacity.

Schedule 14 – Part I
Special Treatment List.

Schedule 14 – Part II
Application for Invasive or Irreversible Treatment.

Schedule 15
Application for Leave under Article 37 for a person detained under Court Order.

Applications for Admission to Mount Carmel Hospital

Schedule 2
Application for a person to be admitted involuntarily for observation in a Licensed Mental Health Facility.

Schedule 13
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 https://get.adobe.com/uk/reader/

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