Patient Name (English):
Patient Name (Chinese):
HKID:
Provisional diagnosis:
Estimated Length of stay: Day(s)
Preferred class of ward: Private Twin Standard
Treatment / surgical operation: (Gastroscopy + Colonoscopy) +/- polypectomy Breast lump excision Bronchoscopy +/- biopsy Caesarean section Caesarean section - auspicious time Carpal tunnel release Circumcision Colonoscopy +/- polypectomy Colposcopy Dilation and Curettage Direct laryngoscopy +/- vocal cord polyp biopsy Flexible Cystoscopy +/- biopsy Gastroscopy +/- polypectomy Haemorroidectomy Hernia repair (Open) Herniotomy Hysterectomy Knee arthroscopy Laminectomy Laparoscopic Cholecystectomy Laparoscopic Colectomy Laparoscopic Ovarian cystectomy Micro-laryngoscopy Open reduction and internal fixation of various fractures Spine fusion Thyroidectomy(Hemi) Tonsillectomy Trigger finger release Vaginal delivery
Attending Doctor:
---------------------------------------------------------------------------------------
Estimated Doctor's Fee: (To be completed by doctor)
Daily Doctor’s Round Fee:
Surgical Fee:
Anaesthetist’s Fee:
Other Specialists’ Consultation Fee:
Other Items and Charges:
