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SHIFA JEDDAH POLYCLINIC King Khalid St.

,
Sharafiya

ENDOSOCOPY REPORT

PATIENT NAME PATIENT ID AGE SEX PHYSICIAN EXAM DATE

INDICATION :

CONSENT :

PREPARATION :

INSTRUMENT :

ANAESTHESIA :

PROCEDURE :

FINDINGS

IMPRESSION :

PLAN :

This report has been reviewed by attending physician

Electronic Date :

Signature
SHIFA JEDDAH POLYCLINIC King Khalid St. ,
Sharafiya

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