Time out

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Patient Name _________________________ Date of Birth___________________


Procedure Name ______________________________________________


  • Colposcopy / IUD / Nexplanon
IUD / Nexplanon / ThinPrep Exp Date______________________
Pregnancy Exclusion Confirmed Method____________________
Pap Result ______________
GC / CT_______________________
  • Required Supplies
  • Consent Verified
  • Hands Washed
  • Allergies_____________________________________________________
  • Blood Thinners ________________________________________________
  • Anesthesia ___________________________________________________
  • Site Sterilized _________________________________________________
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