Union Christian College Union Christian College

Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor
 Union Christian College Union Christian College
Widdoes St., Brgy IV, San Fernando City, La Union Widdoes St., Brgy IV, San Fernando City, La Union

OPERATING ROOM SLIP ( ) Scrub ( ) Circulating OPERATING ROOM SLIP ( ) Scrub ( ) Circulating

Name of student: ____________________________ Name of student: ____________________________

Name of patient: ____________________________ Name of patient: ____________________________

Case/Hospital Number: ____________________________ Case/Hospital Number: ____________________________

Age: ____________________________ Age: ____________________________

Diagnosis: ____________________________ Diagnosis: ____________________________

Operation Performed: ___________________________ Operation Performed: ___________________________

Date of Operation: ____________________________ Date of Operation: ____________________________

Anesthesia: ____________________________ Anesthesia: ____________________________

Surgeon: ____________________________ Surgeon: ____________________________

Name of Scrub Nurse: ____________________________ Name of Scrub Nurse: ____________________________

Signature of Scrub Nurse: ____________________________ Signature of Scrub Nurse: ____________________________

______________________ ______________________ ______________________ ______________________

Name & Signature of Name & Signature of Name & Signature of Name & Signature of
Clinical Instructor Nurse Supervisor Clinical Instructor Nurse Supervisor