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Informed Consent Form 1. Consent of participate in a study: Greeting! My name is NGOR SOPHEAK, HENG VANTHORN, and HONG MENGRA. We are working on this research with the objective of many audits the oral and Maxillofacial surgerys patient who have been treated in the Russian Hospital. Taking data from their clinical record of oral and Maxillofacial surgery department, (January 2011 to January 2012). 2. Purpose of study: The study is conducted in partial fulfillment of the requirements for degree of Doctor Dental Science. This study is aiming to determine of number of patients, the kind and main reason of oral surgery in Russain hospital, Oral and Maxillofacial Surgery Department, (January 2011 to January 2012) in Phnom Penh, Cambodia hospital. You are being asked to participate in this study because you have particular knowledge and experiences that may be important to the study. All the results; That could lead to better intervention and recommendation for future. - What participation Involves? You Data will first be record in order to answer a series of question in the questionnaires that prepare for the study. 3. Confidentiality: We assure you that all the information collected from you will be kept confidential. Your name will not be written on any questionnaire or in any report/ documents that might someone identify you. You mane will not be linked with the research information anywhere. All information collected on forms will be entered into computer with only the study identification number. Confidentiality will be observed an unauthorized person will have no access to the data collected. 4. Risk We do not expect that any harm will happen to you, because of participating in this study are not involve in this examination, it is just Data record from your previous treatment form at hospital. 5. Benefits: The information of your Data record will help to determine the number of patients, The Type and the main reason of oral surgery in the Oral and Maxillofacial Department in Russian hospital, Phnom Penh, Cambodia.

II. Questionnaire A. General Information: Hospital ID: Sex: Male Age: Operation date: N ID (N=sample) : Female: Occupation:

B. Oral and Maxillofacial surgery main question: 1. Dentoalveolar surgery 2. Oral and Maxillofacial Infection 3. Head and Neck pathology 4. Oral and Maxillofacial Trauma 5. Orthognathic Surgery 6. Temporomandibular Joint Disorders 7. Oral Cancer 8. Reconstructive Oral and Maxillofacial Surgery 9. Facial Cosmetic Surgery 10. Syndromes of the Head and Neck