[Hospital Name][HospitalAddr1][HospitalAddr2] [HospitalAddr3] [HospitalAddr4] [HospitalPhone] [HospitalEmail] [HospitalWeb] |
| Patient Name | [PatientName] [Sex] / [Age] | Patient ID | [PatientID] | ||
| Marital Status | [Mstatus] | ||||
| Department | [Department] |
| Diagnosis | [Diagnosis] |
| Surgery Planned | [Surgery] |
| Possible Major Complications | [Complications] |
| Approaximate Cost | [Cost] |
DECLARATION |
| Signature of Patient/Bystander | Name | Date [SurgeryDate] |
| Signature of Doctor | Name Dr. [Doctor] | Date [SurgeryDate] |
| LHRC / IPD / 09 |