Calontir Chirurgeons' Patient Encounter Form Page 2

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Calontir Chirurgeons

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Patient’s Complaint:

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First Aider’s Observation(s):

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First Aid Administered:

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Treating Chirurgeon:

Assisting Chirurgeons:

Modern Name:

___________________________ Modern names:___________________________

Modern Signature:

_______________________

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Date: ____ / ____ / ______

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Time: ____ : ____ am/pm

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