| Document Date: 2007-10-11 23:05:52
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Facility HOSPITAL Med Rec / / MedicalCondition light-headedness / hernia / scar / pain / numbness / cut / REPAIR - FEMALE Femoral hernia / strain on the wound before the tissues / Inguinal hernia / needlestick/sharps injury / HIV / infection / high blood pressure / constipation / nausea / skin rash / heart disease / disorders / permanent scar / / MedicalTreatment incision / antibiotics / / Person CONSENT FORM / / Position specialist surgeon / Date Signature Interpreter / surgeon / INTERPRETER / /
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Med Rec. No……………………………………………………… CONSENT FORM Surname:……………………………………………………………