Mr Usman Ahmed

MBBS PhD FRCS(Tr&Orth)

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ENT TCI TEst

——-UROLOGY SURGERY BOOKING FORM——-

Consultant (*)

——-PATIENT DETAILS——-

Patient Surname (*)

Patient Name (*)

Date of Birth (*)

Hospital Number (*)

PostCode (*)

——-PRIORITY——-

Patient Type
ElectiveEmergency

Priority

Suitable for Daycase
YesNo

Anaestehtic
GARegionalLA

Suitable for Middle Grade List
YesNo

Estimated Operation Time (in minutes including anaesthetic time)

3045607590105120135150

——-SIDE——-

RightLeftBilateral

——-PROCEDURE——-

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

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