Patient Name *
Patient Gender *
Male
Female
Patient Age *
Patient ID Type *
HKID
China ID
Other
Patient ID *
Patient Contact *
Doctor Name *
Clinic Contact *
Diagnosis / OT Name *
Preferred OT Date (Earliest Available) *
Preferred OT Time (From) *
Preferred OT Time (To)
OT Duration *
30 mins
45 mins
1 hr
1 hr 15 mins
1 hr 30 mins
1 hr 45 mins
2 hrs
2 hrs 15 mins
2 hrs 30 mins
2 hrs 45 mins
3 hrs
3 hrs 15 mins
3 hrs 30 mins
3 hrs 45 mins
4 hrs
4 hrs 15 mins
4 hrs 30 mins
4 hrs 45 mins
5 hrs
5 hrs 15 mins
5 hrs 30 mins
5 hrs 45 mins
6 hrs
6 hrs 15 mins
6 hrs 30 mins
6 hrs 45 mins
7 hrs
7 hrs 15 mins
7 hrs 30 mins
7 hrs 45 mins
8 hrs
8 hrs 15 mins
8 hrs 30 mins
8 hrs 45 mins
9 hrs
9 hrs 15 mins
9 hrs 30 mins
9 hrs 45 mins
10 hrs
10 hrs 15 mins
10 hrs 30 mins
10 hrs 45 mins
11 hrs
11 hrs 15 mins
11 hrs 30 mins
11 hrs 45 mins
12 hrs
12 hrs 15 mins
12 hrs 30 mins
12 hrs 45 mins
Anesthesia *
GA
MAC
IVS
SA
LA
Anaesthetist
Preferred Admission Date
Preferred Admission Time
Remarks
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