Universidad Nacional Autónoma de México

FES IZTACALA
Clínica Odontológica Molinito
Protocolo Quirúrgico de la Asignatura de Fundamentos de Cirugía

Fecha ______________________

Nombre del Alumno ________________________________________________ Grupo __________________

DATOS DEL PACIENTE

Nombre ________________________________________________ Edad ____________________ Sexo M

F

Núm. Expediente ____________________________________ Núm. de Recibo

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Compromiso sistemico:______________________________________________________________________
Diente(s) por Extraer
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Justificación de la(s) extracción(es) (Diagnóstico)

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Técnica Anestésica
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*Recorta el área y pega tu radiografía con cinta adhesiva

Firmas

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Autorización Inicio Terminado Alta

Descripción de la Técnica Quirurgica

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