SAINT LOUIS UNIVERSITY

A. Bonifacio Street, 2600 Baguio City

(74) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842
Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

O.R Form 1B
O.R. CIRCULATING
FORM
SURGICAL CIRCULATING in: Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, Municipality/City/Province

Prepared by: TAMAYO, TEANU JOSE GABRILLO

Printed Name with Signature

Date Performed SUPERVISED BY

Case Number SURGICAL PROCEDURE O.R. Nurse On Duty
And Clinical Instructor
Time Started PERFORMED (Name and Signature) Name and Signature
 SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City
(74) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842
Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

O.R. Form 1C
O.R. SCRUB FORM
Minor
MINOR SURGICAL SCRUB in: Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, Municipality/City/Province

Prepared by: TAMAYO, TEANU JOSE GABRILLO

Printed Name with Signature

Date Performed SUPERVISED BY

Case Number SURGICAL PROCEDURE O.R. Nurse On Duty
And Clinical Instructor
Time Started PERFORMED (Name and Signature) Name and Signature

March 22, 2018

Functional Endoscopic Sinus Surgery Zhyra Gail Ducusin Howard M. Eckman
 SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City
(74) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842
Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

O.R Form 1B
O.R. CIRCULATING
FORM
SURGICAL CIRCULATING in: Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, Municipality/City/Province

Prepared by: TAMAYO, TEANU JOSE GABRILLO

Printed Name with Signature

Date Performed SUPERVISED BY

Case Number SURGICAL PROCEDURE O.R. Nurse On Duty
And Clinical Instructor
Time Started PERFORMED (Name and Signature) Name and Signature
 SAINT LOUIS UNIVERSITY
A. Bonifacio Street, 2600 Baguio City
(74) 442-3043; (074) 442-2793; (074) 442-8246 to 48
FAX: (074) 442-2842
Website: www.slu.edu.ph
ACCREDITED BY: PAASCU, LEVEL 3 Accreditation Status, 2013-2016

O.R Form 1A
O.R. SCRUB FORM
Major
MAJOR SURGICAL SCRUB in: Saint Louis University Hospital of the Sacred Heart, Baguio City
Hospital, Municipality/City/Province

Prepared by: TAMAYO, TEANU JOSE GABRILLO

Printed Name with Signature

Date Performed SUPERVISED BY

Case Number SURGICAL PROCEDURE O.R. Nurse On Duty
And Clinical Instructor
Time Started PERFORMED (Name and Signature) Name and Signature