BOOKING FORM SAMPLE by dredwardmark


									OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Quirino Avenue corner Roxas Boulevard Malate, Manila BOOKING FORM NAME: Dela Rosa, Rojem AGE/SEX: 20 years old/male ADDRESS: 2509 Madre Perla St., San Andres Bukid, Manila DATEOF ADMISSION: May 27, 2008 ADMITTING DIAGNOSIS: Esotropion, OU DIAGNOSTICS: CBC with PC (April 18, 2008): WBC: 6.8 LYMP: 29.6 MONOCYTES: 2.3 NEUTROPHILS: 67.2 RBC: 5.22 HGB: 14.9 MCV: 84.3 MCHC: 33.8 RDW: 12.8 CLINICAL CHEMISTRY; BUN: 4.2 Creatinine: 74.45 Cholesterol: 3.37 Triglycerides: 1.09 CXR-AP/L: normal chest findings URINALYSIS: Color: yellow Transparency: clear Epith cells: occasional Mucus thread: occasional Amorphous urates: occasional Pus cells: 0-1/hpf Erythrocytes: 0-1/hpf PROCEDURE: Strabismus operation Hospital Number: 1488315 Room No. Room 219

PHYSICIANS-IN-CHARGE: Dr. Sumajit/Dr. Daffon/Dr. Samaniego/Dr. Corpuz/Dr. Gapay/Dr. Eugenio/Dr. Tormon/Dr. Ibasco CLERKS-IN-CHARGE:Guiling/Osias/Palis/Panao

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