输液港植入知情同意书.docx

输液港植入知情同意书

姓名__________性别__________年龄__________病案号__________科室__________床号__________诊断______________________________目前治疗方案______________________________过敏史：□无□有（具体过敏原：____________________）凝血功能状态：□正常□异常（异常说明：____________________）基础疾病：□无□有（具体疾病：____________________）医保类型：□城镇职工医保□城乡居民医保□