Request edit access
JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.
Operation Theatre Bookings (for clinics only)
Paediatric Surgery and Urology International
1 Orchard Boulevard #02-04
Camden Medical Centre
Singapore 248649
Tel: (+65) 63592679 Whatsapp: (+65) 87727527
Email: care@childsurgery.sg
Sign in to Google
to save your progress.
Learn more
* Indicates required question
Patient's Name
*
Your answer
Gender
*
Male
Female
DOB
*
MM
/
DD
/
YYYY
Does patient have any co-morbidities?
*
Heart conditions
Lung conditions
Brain conditions
Haematology conditions
Nil
Other:
If the answer is Yes to the question above, kindly specify co-morbidities. If answer is Nil to the question above, please input Nil.
*
Your answer
ASA category
1
2
3
4
Clear selection
Patient's Allergy
*
Your answer
Patient's Telephone / Handphone / WhatsApp no
*
Your answer
Nature of Operation
*
Your answer
Date of operation preferred
MM
/
DD
/
YYYY
Time of operation preferred
*
Time
:
AM
PM
Duration of operation in minutes
*
Your answer
Anesthesia Type
*
Local anaesthesia
Oral Sedation
IV Sedation
General anaesthesia
Surgeon's Name
Your answer
Anesthetist's Name. If no anaesthetist, input Nil
*
Your answer
Special instructions/ Equipment Required
Your answer
Billing
*
Bill Clinic
Bill Patient
Accommodation Required
*
Day Surgery Bed
Day Surgery Suite
Other:
Overnight Stay Required?
No overnight stay.
Overnight stay required.
Clear selection
Name of Clinic
Your answer
Name of Clinic Staff
*
Your answer
Staff Telephone / Handphone / WhatsApp number
Your answer
Requests or Questions
Your answer
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Paediatrics, Surgery and Urology Pte. Ltd..
Report Abuse
Forms
