On conducting of medical interference

(diagnostic inspection and manipulation treatments)

I_________________________, by this document confirm the fact of grant

(patient’s last name, name, year and place of birth)

the offered me consent on the plan of inspection and medical treatment, that includes:

I confirm that in a fully clear form the information on my disease, order of inspection, diagnosis, possible prognosis, risks and complications of medical treatment, and also methods of medical treatment most effective for me was given to me. Possibility of all questions was given to me, that I was interested in relation to subsequent medical interferences, and also to get on them the answers exhaustive and clear for me.

Doctor_________________________________________________________ (last name, name)

which will carry out interference, and other medical workers of Sumy region infectious clinical hospital named after Z.Y. Krasovitsky, where it will be carried out. I agree with the plan of inspection and manipulation treatments offered me. Text of this consent is readed by me and the own signature I certify that I fully agree with all, that it is marked in it.

_________________________ __________________

(signature) (patient’s last name, name)

Date_______________200__year.

This document is readed and signed by a patient____________________

(patient’s last name, name)

Doctor _____________________ ___________________

(signature) (patient’s last name, name)

With the item 19, 20, 38 of the law of Ukraine “About defence of population from infectious diseases” in relation to persons’ rights and duties which have infectious diseases or are bacteriacarriers and responsibility of the failure of sanitary norms and rules is acquainted.

Signature of the patient ________________________

TEMPERATURE LIST (example)

Card № 1021 Last name, name of the patient Pilipenco Philip Ward № 6

Date

1.03.08

2.03.08

3.03.08

4.03.08

5.03.08

6.03.08

7.03.08

8.03.08

8.03.08

9.03.08

10.03.08

11.03.08

Day of illness

Day of staing at the department

Pulse

AT

T 0С

m

iv

m

iv

m

iv

m

iv

m

iv

m

iv

m

iv

m

iv

m

iv

r

in

r

in

r

in

exanthema

hepatosplenomegaly

Breathing / min

Mass, kg

Liquids are used, ml

Diuresis Color

yellow

yellow

yellow

yellow

yellow

l. yellow

l. yellow

l. yellow

l. yellow

Stool / day Admixtures: blood mucus

-

-

1 of.

-

-

-

-

-

-

-

-

-

-

-

-

-

-

Reverse page Of The LIST of medical setting

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