Adult Triage Form Page 1

R.K.
KHAN HOSPITAL ADULT TRAUMA TRIAGE FORM
PATIENT NAME : ________________________________ DATE : __________________
OUTPATIENT NO. : _______________________ TIME : __________________
HISTORY
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________SIGN : _______________________________________
I HEREBY ACCEPT TREATMENT RENDERED UPON YSELF / NEXT OF KIN : ________________________________________________________________________________
NURSES' SIGNATURE / WITNESS : ________________________________________________________________________________________________________________________
DOCTOR'S NAME : ______________________________________________________________ M.P. NO. : ________________________________________
TIME : _________________________________________ DATE : ________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
PRESCRIPTION MUST INCLUDE DOCTORS FULL SIGNATURE / QUALIFICATIONS

Adult Triage Form Page 1

Загружено:

Сведения о документе

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

Adult Triage Form Page 1

Загружено:

Авторское право:

Доступные форматы

R.K.

KHAN HOSPITAL ADULT TRAUMA TRIAGE FORM

PATIENT NAME : ______________ DATE :

OUTPATIENT NO. : _____ TIME :

I HEREBY ACCEPT TREATMENT RENDERED UPON YSELF / NEXT OF KIN : ________________________________________________________________________________

NURSES' SIGNATURE / WITNESS : ________________________________________________________________________________________________________________________

DOCTOR'S NAME : ______________________ M.P. NO. :

TIME : _ DATE :

Вам также может понравиться