Form K 2

Patient Name

Date of Birth (dd/mm/yyyy)

Hospital ID ( UID, MRN)

Gender ( Male/Female)

Hospital Name, City (Location)

Operation Date (dd/mm/yyyy)

Anaesthesia Type

Surgeon Incharge

Side ( Left/Right)

Procedure Type ( Single stage/ Stage I/Stage II/ Amputation/Arthrodesis)

Indication For Revision

Primary Operation Date (dd/mm/yyyy)

Prosthesis Removed ( Brand)

Surgical Approach Used

Bone Grafting ( Yes/No)

Revision Implant Used

Complications If any

Surgeon UID

Form K 2 (Knee Revision)