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R.K.

KHAN HOSPITAL ADULT TRAUMA TRIAGE FORM

PATIENT NAME : ________________________________ DATE : __________________

OUTPATIENT NO. : _______________________ TIME : __________________

HISTORY
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____________________________________________________________________________________________________________SIGN : _______________________________________

I HEREBY ACCEPT TREATMENT RENDERED UPON YSELF / NEXT OF KIN : ________________________________________________________________________________

NURSES' SIGNATURE / WITNESS : ________________________________________________________________________________________________________________________

DOCTOR'S NAME : ______________________________________________________________ M.P. NO. : ________________________________________

TIME : _________________________________________ DATE : ________________________________________

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PRESCRIPTION MUST INCLUDE DOCTORS FULL SIGNATURE / QUALIFICATIONS