REQUEST FOR SURGERY APPROVAL
Revision: R01
DOI: 17/06/2023
DOR: 17/06/2028
WBM-ITD-002-FM003-003
Name | : Peter A J | Nationality | : Indian |
Date of Birth | : 11/12/1998 | MRN | : 001234 |
Gender | : Male | Date of Surgery | : 06/08/2018 |
PROCEDURE/PRIVILEGES INFORMATION (ATTACHED PRIVILAGE) | |||
---|---|---|---|
Procedure 1 | : | ||
Procedure 2 | : | ||
Procedure 3 | : | ||
Additional Procedure(if Any) | : | ||
SURGEONS | |||
Surgery Date | : 12/03/2022 | Surgery Time | : 10 am |
Surgeon (primary/Assistat) | : | Surgeon (primary/Assistat) | : |
Signature and Stamp of First Surgeon | Signature and Stamp of First Surgeon | ||
Date : |
Date : |
APPROVAL | ||||
---|---|---|---|---|
Head of Surgical Division | ||||
Name | : Dr. Amr Aboulwafa | |||
Date | : | |||
Approved | Rejected | |||
Justification if Rejected : |
Signature and Stamp :
Date : |
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