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Tracheotomy / Consent / Laryngectomy / Surgery / Blood transfusion / Tracheo-oesophageal puncture / Medicine / Otolaryngology / Surgical oncology


Med Rec. No……………………………………………………… CONSENT FORM Surname:……………………………………………………………
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Document Date: 2007-10-11 23:05:50

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File Size: 209,98 KB

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MedicalCondition

light-headedness / cut / needlestick/sharps injury / HIV / high blood pressure / constipation / nausea / tumour / skin rash / heart disease / disorders / /

MedicalTreatment

radiotherapy / speech therapy / surgery / blood transfusion / antibiotics / /

Person

CONSENT FORM FOR LARYNGECTOMY / /

Position

Date signature Interpreter / surgeon / specialist ENT surgeon / ENT surgeon / INTERPRETER / /

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