Professional Documents
Culture Documents
0630 - Implants Form
0630 - Implants Form
DEPARTMENT OF HEALTH
Regional Office IV-MIMAROPA
OSPITAL NG PALAWAN
Name:
Name:
Name:
Age/Sex:
Age/Sex:
Age/Sex:
PHIC:
Reg. PHIC
NBB
Non-
PHIC:
Reg. PHIC
NBB
Non-
PHIC:
Reg. PHIC
NBB
PHIC
PHIC
PHIC
Admitting Diagnosis:
Admitting Diagnosis:
Admitting Diagnosis:
YES
NO
YES
NO
YES
Non-
NO
NEED TO OUTSOURCE
NO
INSTRUMENTS/IMPLANTS:
YES
NEED TO OUTSOURCE
NO
INSTRUMENTS/IMPLANTS:
YES
NEED TO OUTSOURCE
NO
INSTRUMENTS/IMPLANTS:
YES
MEDICAL ASSISTANCE
NO
YES
MEDICAL ASSISTANCE
NO
YES
MEDICAL ASSISTANCE
NO
YES
DIAGNOSTIC PROCEDURE
AVAILABLE IN HOSPITAL
REMARKS:
YES
NO
DIAGNOSTIC PROCEDURE
AVAILABLE IN HOSPITAL
REMARKS:
YES
NO
DIAGNOSTIC PROCEDURE
AVAILABLE IN HOSPITAL
REMARKS:
ATTENDING PHYSICIAN
ATTENDING PHYSICIAN
ATTENDING PHYSICIAN
APPROVED BY:
APPROVED BY:
APPROVED BY:
YES
NO