DEPARTMENT OF ANESTHESIOLOGY
BICOL REGIONAL TRAINING AND TEACHING HOSPITAL
CLERK/INTERNS COMPLETION FORMS
NAME: DATE OF ROTATION: SCHOOL:
CASE
NUMBER/
DATE
NAME/AGE OF
PATIENT
DIAGNOSIS PROCEDURE ANESTHETIC
TECHNIQUE
ANESTHESIOLOGIST SIGNATURE
ERLEEN SEYCHELLE M. YU, MD
Clerks & Interns Monitor
EDGAR A. REFRAN, MD, DPBA
Training Officer
