Referring Anaesthetist: * Procedure date: * MM DD YYYY Intended procedure/code: * Intended Surgeon/Hospital: * Patient demographics (MRN + D.O.B.): * Relevant clinical history: * Cancellation period to the procedure: * Same day Within 24hrs Within 72hrs +72hrs Reason for cancellation: * Medically unfit for anaesthesia (newly diagnosed condition) Logistical reasons (surgical/theatre/anaesthetic) Other Date you reviewed the patient: * MM DD YYYY Did the patient attend pre-op? * Yes No Was the cancellation communicated to the patient? * Yes No Was the cancellation communicated to the patient's family? * Yes No Was the cancellation discussed with the surgeon? * Yes - Verbally Yes - Verbally & letter written No Does the procedure require to be rescheduled? * Yes No Does this patient require further work up? * Yes No Have you referred this patient? If yes, please advise who? * Thank you!
