Background: Referral system constitutes a key element of health system and one of the strategies for ensuring the best use of hospital resources and health care services.. Aim and objectives: a) Causes behind of direct attendance of patients to hospital. b) Find out the main reasons of patients referral to hospital. c) Patients' opinion about the hospital services. d) Assess consultants view about referral system. Methods: A cross sectional study was carried out since 1st of March 2018 till end of September 2018. 1000 patients attending seven consultation units in Azadi teaching hospital were involved in the study. Anevaluation of main causes of direct attendance was done, review of the information on the referral form, patient satisfaction with referral was inquired and specialist doctors' evaluation of the referral was obtained. Results: The rate of referral with referral form was (81%). Main cause of direct attendance was that patients don’t trust the Primary health care center (PHCC) doctor. The provisional diagnosis,a reason for the referral and name of the referring doctor were absent or unclear on (94.6, 84.1 and 61.9 %) of referral forms..Patient satisfaction with the services of secondary health care facilities was (80.1%), and the highest rates of dissatisfaction were because of drug unavailability in hospitals. Specialist doctors considered (55.1%) of all referrals as inappropriate and the need for further treatment was the main reason for indicated referrals. Conclusion: The rate of patient’s referral with referral form was high. The main cause of directly attending hospital with no referral form is that patients do not trust doctors in PHC level. Patients are generally satisfied with the services of secondary health care facilities. More than half of referred cases not need referral from the specialists’ point of view.