Republic of the Philippines

DEPARTMENT OF HEALTH
Regional Office IV-MIMAROPA
OSPITAL NG PALAWAN

Republic of the Philippines

DEPARTMENT OF HEALTH
Regional Office IV-MIMAROPA
OSPITAL NG PALAWAN

Republic of the Philippines

DEPARTMENT OF HEALTH
Regional Office IV-MIMAROPA
OSPITAL NG PALAWAN
CLEARANCE FOR ELECTIVE SURGICAL
CASES
Hosp. #:
Date:

CLEARANCE FOR ELECTIVE SURGICAL

CASES
Hosp. #:
Date:

CLEARANCE FOR ELECTIVE SURGICAL

CASES
Hosp. #:
Date:

Name:

Name:

Name:

Age/Sex:

Age/Sex:

Age/Sex:

PHIC:

Reg. PHIC

NBB

Non-

PHIC:

Reg. PHIC

NBB

Non-

PHIC:

Reg. PHIC

NBB

PHIC

PHIC

PHIC

Admitting Diagnosis:

Admitting Diagnosis:

Admitting Diagnosis:

Contemplated Surgical Procedure:

Contemplated Surgical Procedure:

Contemplated Surgical Procedure:

NEED FOR IMPLANT:

YES

NO

NEED FOR IMPLANT:

YES

NO

NEED FOR IMPLANT:

YES

Non-

NO

NEED TO OUTSOURCE
NO
INSTRUMENTS/IMPLANTS:

YES

NEED TO OUTSOURCE
NO
INSTRUMENTS/IMPLANTS:

YES

NEED TO OUTSOURCE
NO
INSTRUMENTS/IMPLANTS:

YES

MEDICAL ASSISTANCE
NO

YES

MEDICAL ASSISTANCE
NO

YES

MEDICAL ASSISTANCE
NO

YES

DIAGNOSTIC PROCEDURE
AVAILABLE IN HOSPITAL
REMARKS:

YES

NO

DIAGNOSTIC PROCEDURE
AVAILABLE IN HOSPITAL
REMARKS:

YES

NO

DIAGNOSTIC PROCEDURE
AVAILABLE IN HOSPITAL
REMARKS:

ATTENDING PHYSICIAN

ATTENDING PHYSICIAN

ATTENDING PHYSICIAN

APPROVED BY:

APPROVED BY:

APPROVED BY:

YES

NO