——-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
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
