INFORMATIVE FORM FOR IN PATIENT TREATMENT | Gan Direct

INFORMATIVE FORM FOR IN PATIENT TREATMENT

If you are human, leave this field blank.

INFORMATIVE FORM FOR IN PATIENT TREATMENT

To be completed by the treating doctor/surgeon

GENERAL

NAME OF PATIENT:

ADMISSION OR START DATE OF TREATMENT:

PLACE OF TREATMENT:

IF OTHER, PLEASE SPECIFY:

TREATMENT

CAUSE OF ADMISSION/TREATMENT (Diagnosis or differential diagnosis – NOT symptoms: see below):

IMPORTANT CLINIC-LABORATORY FINDINGS OR THE MAIN SYMPTOMS THAT NEED TREATMENT:

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