yy A DR DE KLERK TAUTE f ’ Al sATI BE! 1 PATIENT: MR KL MARAIS ID: 010418 5239 084 TEL: 072 3318 488 OPERATION - 34 Metacarpal Fracture: RIGHT Hand CPT code: 26615 Open treatment of metacarpal fracture single includes internal fixation DATE OF SURGERY: 16 February 2024 PROCEDURE CODES: 0614 Arthroplasty Debridement 0680 Joint ligament reconstruction or suture: 0501 Grafts to cysts: Small bones 0405 Fracture 0051 Fractures requiring open reduction 0009 Assistant IMPLANTS: PHILLIP - 6-HOLE PLATE ALL OPERATIONS: 1. Bring your Medical Aid number, .D. Book & Authorisation number. 2. Bring X-rays if any. 3, Remove nail polish & all jewellery. 4, SMS will be sent to tell you at which time you will be admitted at hospital and when to stop eat and drink. You will be admitted at Mediclinic hospital 5. You will be discharged the following morning after 09:00. Please arrange for someone to drive you home. NOTE: PHYSIOTHERAPY MAY BE REQUIRED POST OPERATIVELY AT THE REQUEST OF THE DOCTOR. THIS WILL BE CHARGED | SEPARATELY BY THE PHYSIOTHERAPY PRACTICE CONCERN MBChB, MED ORTHO (UFS) MP 0589578 PR 0550876Dr. J.D. Taute MediClinic Potchefstroom Suite 203 Orthopedic Surgeon Tel: (018) 294-4479 MB.ChB M.MED (Ortho)(UFS) drtaute@orthosport.co.za PR 0550876 Informed Consent patient: _ Mr_kL Moras patesizned: I - 02-2024, 3rd Metacarpal oniF:(R) Hand, Proposed Procedu | the undersigned hereby give consent to the perforrhance of the above procedure by Dr Taute. | have been informed about possible risks including but not limited to anesthetic complications, Infections risk, venous clots, failure of surgery, medication reaction and possible implant complications. | understand that any underiying medical condition thi peri operative compl | might have increases my risk of possible yns.Dr D Taute has explained to me why this procedure is indicated and hy in his view alternative therapy is not 2 viable option. understand that the planned procedure has been recommended to me by Dr D Taute but that continuation of treatment depends on my own wishes. In the event that complications arise i hereby authorize Dr D Taute to provide me with appropriate ‘treatment to the best of his ability and also aut ‘optomize my treatment. 12 him to consult wi sther practitioners to Thereby authorize the use of blood products should they be deemed appropriate by Dr JD Taute. understand the underlying risks of the Covid-19 pandemic. | declare thet t have not had any contact with anyone that is/was Covid positive. my best knowledge I also declare that | zm not Covid positive or show any simptoms associated with the virus. | will not hold the Doctor (Dr JO Taute) or the hospital (Mi ‘Mooimed Hospital) liable should | contract the virus or any rmplications 2 sa result Should | have any questons or need any fu information cons Parent/Patient GuardianDR DE KLERK TAUTE ORTHOPAEDIC SURGEON / ORTOPEDIESE CHIRURG 1 PATIENT DETAILS PASIENT BESONDERHEDE “Account Number Rekening Nommer gumame Morais First Name Voornaam, Casper L hMrsiMiss inr/MeviMe} eee (e204. 200! 1oN. C1OULS 5931 O8y can ee ceria bl vara Single Te) Tow ~ Sl O72 3318 YRS Enel E-pos Marais 146 @ quail. CoM Palleni Dependant Code _¢ | Pasiant Athankike Kode 2 PERSON RESPONSIBLE FOR ACCOUNT (MAIN MEMBER OF MEDICAL AID) PERSOON VERANTWOORDELIK VIR REKENING (HOOFLID VAN MEDIESE FONDS) Tana, KL Mdrans More WN OW 533% O84 esas roaress 15 Bach Ave, vd Hottpork , PotcheFstrocm fee 253 | Home Aaaess ” " ‘ Kose 253] Wongener__ ORI EMal AdKESS MATHS Io © Atholl. CoN Tel) Tel. 0) Sel O12 3318 4 88 3 MEDICAL AID MEDIESE FONDS Rare Medinelp Number BOY. 92bb any Geae’ Nea elect [RmnonuO 4 NEAREST FAMILY/FRIEND NAASTE FAMILIE/VRIEND Name Petro Marais Naam Cores Ma Ta.) [eo ce! ova 454 85a7 5 REFERRING DR OR HOUSE DR VERWYSENDE DR OF HUIS DR Nae Dee e Naam 6 CONDITIONS hereby agree that the above information are true and correct. | agree that | am liable for claims not paid by my Medical Aid. Signature: Tel 6 VOORWAARDES Hiermee bevestig ek dat die bogenoemde waar en korrel is. Ek bly verantwoordelik vir eise wat nie deur my Medie: Fonds betaal word nie. Handtekening: Beeat ECTS ea Ve ld essoo ‘SOUTH APRILA: yosse0133 2 emwemamnuanuvirt