Professional Documents
Culture Documents
Given Names:
Address:
Facility: ..............................................................................................................................................
Date of Birth:
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Given Names:
Address:
Facility: ..............................................................................................................................................
Date of Birth:
Sex: M
Name of Patient/
Substitute decision
maker and relationship: .......................................................................................................
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Signature:............................................................................................................................................
F. ANAESTHETIC
Date: ...................................................................
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G. PATIENT CONSENT
H. DOCTORS STATEMENT
I.
INTERPRETERS STATEMENT
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2. MY ANAESTHETIC
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