|
Patient Name
|
Facility
|
|
Surgeon
|
|
|
Assistant: Alexis
|
|
|
Assistant: Dr. Bray
|
|
|
No Assistant
|
|
|
Pre-Operative Diagnosis
• • •
|
Pre-Operative Diagnosis (Other):
|
|
Post-Operative Diagnosis
|
|
|
Procedure(s) performed:
|
|
|
Microscope used?
|
|
|
Anesthesia
|
|
|
Complications
• • •
|
|
|
Complex Case?
|
|
|
Estimated Blood Loss:
• • •
|
|
|
Indications:
|
|
|
Procedure:
|
|
|
Salutation
|
|
