输尿管镜知情同意书.docx

输尿管镜知情同意书

姓名：____________________性别：□男□女年龄：________岁科室：____________床号：________住院号：________________身份证号：________________________________户籍/常住地址：________________________________________________________________紧急联系人姓名：____________与患者关系：________

术前诊断：___________________________________________