Elective Surgery Form - Saint James Hospital Malta

Elective Surgery Plan

Patient Details

First Name*

Last Name*

Phone number*

ID card/Passport no.

Date of birth*

Sex*

Insurer

FOR BOOKING OFFICE USE: CCSD SCHEDULE/CODE

Surgery Plan

Surgery Location

Sliema

Zejtun

Proposed Date & Time

Date

Time

Procedure Name *

Left

Right

Both Sides

Insurance Report

The description of the symptoms/complaints including history of symptoms

Diagnosis

The recommended plan of treatment, including the surgery details

Anaesthesia Type*

Cross Match

No of packed RBC units needed:

Special Equipment / Implants Required

Investigations

Saint James Hospital Preoperative Assessment Clinic follows the NICE Guideline “Routine Preoperative Tests for Elective Surgery”. List below only additional investigations required:

Is patient on Anticoagulant Therapy?

If yes, please specify:

Surgeon Name

First

Last

Date of Submission

Date

This field should be left blank

Elective Surgery Plan

Patient Details

Surgery Plan

Insurance Report

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