DATA PREVISTA CIRURGIA: _________ /_________ /__________.

LOCAL: _______________________________________________________________

PACIENTE: __________________________________________________________________________________________________________________________________________

PROCEDIMENTO: ___________________________________________________________________________________________________________________________________

▪ CHECK LIST DE CIRURGIA

TEM PLANO DE SAÚDE: SIM NÃO QUAL: _________________________________________________________________________________________

EXAME DE COVID TERMO DE CONSENTIMENTO

CIRURGIA SEGURA CONTRATO FINANCEIRO

RELAÇÃO DE EXAMES:

EXAMES LABORATORIAIS ULTRASSOM DE MAMA

EXAME DE URINA (EAS) MAMOGRAFIA

RISCO CIRÚRGICO ULTRASSOM PAREDE ABDOMINAL

EXAME DE ECG ULTRASSOM ABDOMINAL TOTAL

RX-TÓRAX PA/PERFIL DOPPLER VENOSO DE MMII

OUTROS: ________________________________________________________________________________________________________________________________________

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CIRURGIA PRECISA DE AUXILIAR: SIM. NÃO

1º AUXILIAR: ______________________________________________________________________________________________________________________________________

2º AUXILIAR: _______________________________________________________________________________________________________________________________________

PRÓTESES SILIMED

SOLICITADAS PELO MÉDICO: _____________________________________________________________________________________________________________________

DISPONIBILIZADAS PELA SILIMED: ______________________________________________________________________________________________________________

INFORMAÇÕES DE PAGAMENTOS:

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MODELADORES:

CINTA COMPLETA FEMININA - ( ) TAM. ( ) QTD CINTA MASCULINA COMPLETA – ( ) TAM. ( ) QTD

MEIA ANTI-TROMBO – ( ) TAM. ( ) QTD COLETE PARA GINECOMASTIA – ( ) TAM. ( ) QTD

FAIXA DE ORELHA – ( ) TAM. ( ) QTD COLETE ESPONJA RENUVION – ( ) TAM. ( ) QTD

CINTA DE BRAÇOS – ( ) TAM. ( ) QTD KIT PLACAS: ( ) LATERAIS ( ) SACRAL ( ) FRONTAL

SUTIÃ PÓS CIRÚRGICO – ( ) TAM. ( ) QTD ÓRTESE DE UMBIGO – ( ) QTD.

OBSERVAÇÕES E/OU PENDÊNCIAS:

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