Bed Booking Form: PICU

Surgical Post-operative Bed Booking Form: PICU

Please fill in all information below at least 24 hours prior to bed being required. If it is less than 24 hours until surgery, contact the PICU directly.

* Indicates required field

Patient Name *

First

Last

Hospital Registration Number *

Date of Birth (DD/MM/YYYY) *

Gender *

Male Female Indeterminate

Weight (in kilograms) *

If Location is "Other", please specify *

If specialty is "Other", please specify *

Consultant's Name *

Planned Date of Surgery *

Diagnosis/Diagnoses *

Details of proposed surgery.

Planned procedure (including location on body) *

Post op drains *

Yes No

Locations of drains, if yes *

Expected duration of case *

Type of surgery *

Routine Urgent

Previously cancelled *

Yes No

Patient details concerning PICU course.

Pre-existing airway/lung disease *

Yes No

Details if yes or post-op *

Tracheostomy in situ *