SR. DATE NAME OF PATIENT AGE/SEX IP/UHID NO.

NO.
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DIAGNOSIS NAME OF SURGERY NAME OF SURGEON ANASTHESIA

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MODIFICATION OF TIME OF
NAME OF ANAESTHETIST ANAESTHESIA REASON FOR MODIFICATION PATIENT
FROM-TO WHEEL IN
TIME OF PATIENT NAME OF ANTIBIOTIC GIVEN SIGN. OF SIGN. OF
WHEEL OUT SURGEON TECHNICIAN