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INFORMATIVE FORM FOR IN PATIENT TREATMENT
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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:
TYPE OF MEDICAL CONDITION:
PATHOLOGICAL
SURGICAL
ORTHOPEDICS
PEDIATRIC
CHEMOTHERAPY
SHORT THERAPY
RADIOTHERAPY
OTHER
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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