|
Accompanied by
• • •
|
Unaccompanied
|
|
Procedure
|
Date of surgery
|
|
Surgeon
|
Hospital
|
|
Other concerns
|
|
|
|
|
|
Head circumference
|
|
|
|
|
|
Exam
|
|
|
|
|
|
Cleared for surgery
|
|
