Name:		C.I.
Speciality:
Telephones:	Doctor's office:	Cellular telephone:
	Fax::	Search presents:
Surgical intervention:
	Requested:
	Time: 1/2 hora 1 hora 2 horas 3 horas 4 horas 5 horas 6 horas
	Ambulatory	Hospitalization
	Days of hospitalization
Honorarium:	$: Principal surgeon
	$: The first Assistant %
	$: The second Assistant %
	$: Other one:
	$: Anestesiólogo %
	Type::
Special equipments:	Laser	$:
	Lipoescultor	$:
	Prothesis M.	$:
	Mat. Special	$:
	Inst. Special	$:
	Video Endoscopia	Bsd.
	Microscope	Bsd.
	Artroscopia	Bsd.
	Radiology (Plate of location)	Bsd.
	Laparoscopia	Bsd.
	Turnstile	Bsd.
	Arch in C	Bsd.
	Consultation	Bsd.
	Laboratory	Bsd.
	Cardiovascular evaluation	Bsd.
	Ecosonograma	Bd.
	Others
Pathological anatomy:	Untimely (piece)
		$:
	Definitive (piece) )
		$:
Information of the Patient:
Personal information:	Name:	C.I.
	Age Years	Sex: F M
	Telephones:
Type of payment	Individual
	Credit card Check Cash
	Assurance
	Company	Number of Policy:
	Holder Beneficiary
Method of payment to doctors	45 Days 3 Days
Observaciones:
	Date and tentative hour of the intervention:
	Date:	Hour: AM PM