PRE REGISTER

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MEDICAL INFRMATION: (PLEASE RECORD PATIENTS ACTUAL HEIGHT AND WEIGHT)

NOTE: ALL LABS/ECG/MEDICAL CLEARANCE MUST BE RECEIVED AT LEAST AT LEAST 1 WEEK PRIOR TO SURGERY TO AVOID POSSIBLE CANCELLATION. IT WILL BE AT DISCRETION OF ANESTHESIA TO TO CANCEL THE CASE IF INFORMATION IS NOT RECEIVED OR RESULTS ARE ABNORMAL

MEDICAL AID INFORMATION: PLEASE PROVIDE A COPY OF MEDICAL AID CARD BOTH FRONT AND BACK

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