ENT TCI TEst -------UROLOGY SURGERY BOOKING FORM------- Consultant (*)—Please choose an option—ENT 1ENT 2 -------PATIENT DETAILS------- Patient Surname (*) Patient Name (*) Date of Birth (*) Hospital Number (*) PostCode (*) -------PRIORITY------- Patient Type ElectiveEmergency Priority [radio Priority label_first use_label_element default:0 "Routine" "Urgent" Case to be done within how many weeks? [number* Urgent max:24 placeholder] Suitable for Daycase YesNo Anaestehtic GARegionalLA Suitable for Middle Grade List YesNo Estimated Operation Time (in minutes including anaesthetic time) 3045607590105120135150 -------SIDE------- RightLeftBilateral -------PROCEDURE------- —Please choose an option—TonsillectomylaryngectomyOther Tonsillectomy surgery for recurrent tonsilitis criteria Sore Throat due to Tonsilitis YesNo disabling and preventing normal function YesNo seven or more severe sore throats YesNo Procedure Details -------REQUIREMENTS------- Interpreter YesNo Which Language Ultra Clean Theatre YesNo Image Intensifier RadiographerMini C-ArmNot Required Loan Kit YesNo Kit Required -------MEDICATIONS------- Anticoagulation (check all that apply) WarfarinAspirinClopoidogrelApixaban/Rivaroxiban Is the patient on HRT/OCP?YesNo Is the patient on Diabetic?YesNo -------ALLERGIES------- Latex AllergyYesNo Allergies [wpcf7pdf_download] Δ Views: 126
