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<td align="center" class="FormInsideTableRegCell"> </td>
</tr>
<tr>
<td height="20" colspan="4" class="FormInsideTableRegCell"> Stricture:<span class="smallGrayText">
<img src="../../Images/shim.gif" border="0" width="40" height="1">Location:
___________________ <img src="../../Images/shim.gif" border="0" width="40" height="1">Caliber:
___________________ French</span></td>
</tr>
</table></td>
</tr>
<tr>
<td height="500" align="center" class="FormOuterTableRow"><img src="../../Images/FormImages/Bladder6.gif" width="600" height="447"></td> </tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU06<img src="../../Images/shim.gif" border="0" width="45" height="1">U10<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="1">rev:08/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
2 of 3<img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">06</span></td>
</tr>
</table>
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<div id="LastPageInForm" runat="server" align="center" style="page-break-before:always;">
<div align="center">
<div align="right" class="VerticalBarCodeDiv">
<div class="VerticalBarCodeStatement"><img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"><br/>
<img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121" vspace="220"><br/>
<img src="../../Images/FormImages/BarCodeLineStatement.gif" border="0" width="8" height="121"></div>
<div class="VerticalBarCodeMRN"><% =BarCodeMRN %></div>
<div class="VerticalBarCodeDocType">*U10*</div>
<div class="VerticalBarCodeAcctType"><% =BarCodeAcctType %></div>
<div class="VerticalBarCodeDate"><% =BarCodeDate %></div>
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<font style="font-size: 12px;">CONTAINS PROTECTED HEALTH INFORMATION - HANDLE ACCORDING TO MSKCC POLICY</font>
<table width="650" border="0" cellspacing="0" cellpadding="0">
<tr>
<td class="FormOuterTableTopRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
<tr>
<td width="325" align="center" valign="middle" class="FormInnerRowRightBorder"><img src="../../Images/FormImages/<%= institutionShortName%>_FormLogo.gif" width="90" alt="" border="0" align="left"><span class="blackBoldText"><%= institutionName%><br>
Urology Endoscopy OR Patient</span></td>
<td width="325" align="center" valign="bottom">
<table width="325" border="0" cellspacing="1" cellpadding="0" >
<tr>
<td width="65"><img src="../../Images/shim.gif" border="0" width="65" height="1"></td>
<td align="left" width="260"><img src="../../Images/shim.gif" border="0" width="260" height="1"></td>
</tr>
<tr>
<td align="right"><% =patientMRNLabel %> </td>
<td align="left"><strong><% =patientMRN %></strong> <% =patientDOB %></td>
</tr>
<tr>
<td colspan="1" align="right"><% =patientNameLabel %> </td>
<td colspan="1" align="left"><strong><% =patientLastName %>, <% =patientFirstName %> <% =patientMiddleName %></strong></td>
</tr>
<tr>
<td align="right" valign="top"><% =patientAddressLabel %> </td>
<td align="left" valign="top"><% =patientAddress1 %><% =patientAddress2 %><% =patientCity %> <% =patientState %> <% =patientPostalCode %></td>
</tr>
<tr>
<td colspan="2"><img src="../../Images/shim.gif" border="0" width="1" height="5"></td>
</tr>
<tr>
<td colspan="2" align="center" valign="bottom" class="blackBoldText">Patient Identification</td>
</tr>
</table>
</td>
</tr>
</table></td>
</tr>
<tr>
<td height="20" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="1"><span class="blackBoldText">Date: <% =apptClinicDate %></span></td>
</tr>
<tr>
<td class="FormOuterTableRow"><table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Bimanual
Examination Findings</span><span class="smallGrayText"> <img src="../../Images/shim.gif" border="0" width="30" height="1">
<input type="checkbox" name="Nurse21325" value="Yes">
</span>Normal<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21335" value="Yes">
</span>Abnormal<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21343" value="Yes">
</span>Mass<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21353" value="Yes">
</span>Induration</td>
</tr>
<tr>
<td height="35" colspan="2" class="FormInnerRowBottomBorder"><br>
Induration / Thickening Location: ______________________________________</td>
</tr>
<tr>
<td width="325" valign="top" class="FormInnerRowRightBorder">Mass
Size:<br> <br>
_________ cm x _________ cm x
_________ cm <br> <br> <br></td>
<td width="325" valign="top">Involvement of:<br> <br> <span class="smallGrayText">
<input type="checkbox" name="Nurse2133522" value="Yes">
</span>Vagina<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2134323" value="Yes">
</span>Rectum<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse2135323" value="Yes">
</span>Cervix<br> <br> <span class="smallGrayText">
<input type="checkbox" name="Nurse21343222" value="Yes">
</span>Urethra<img src="../../Images/shim.gif" border="0" width="30" height="1"><span class="smallGrayText">
<input type="checkbox" name="Nurse21353222" value="Yes">
</span>Pelvic Sidewall<img src="../../Images/shim.gif" border="0" width="30" height="1">Right<img src="../../Images/shim.gif" border="0" width="30" height="1">Left<br>
</td>
</tr>
</table></td>
</tr>
<tr>
<td height="100" valign="top" class="FormOuterTableRow"><img src="../../Images/shim.gif" border="0" width="4" height="15"><span class="blackBoldText">Preliminary
Recommendations</span></td>
</tr>
<tr>
<td class="FormOuterTableRow"> <table align="center" border="0" width="650" cellpadding="4" cellspacing="0">
<tr>
<td colspan="2" class="FormInnerRowBottomBorder"><span class="blackBoldText">Disposition</span></td>
</tr>
<tr>
<td width="450" align="center" class="FormInnerRowRightBorder"> <table width="440" border="0" cellpadding="0" cellspacing="0">
<tr>
<td width="100" height="25">Prescriptions:</td>
<td width="80" align="center">No<img src="../../Images/shim.gif" border="0" width="22" height="1">Yes:</td>
<td>Refill or New</td>
</tr>
<tr>
<td height="25" colspan="3">Rx: __________________________________________________________</td>
</tr>
<tr>
<td height="25" colspan="3">Rx: __________________________________________________________</td>
</tr>
<tr>
<td height="25">Chemo Orders:</td>
<td align="center">No<img src="../../Images/shim.gif" border="0" width="22" height="1">Yes:</td>
<td>____________________________________</td>
</tr>
</table></td>
<td width="200" align="center"> <span>Protocol #: ________</span>
<br> <table align="left" width="100%">
<tr>
<td>Considered:</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="0">No</td>
</tr>
<tr>
<td>Consent Obtained:</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="0">No</td>
</tr>
<tr>
<td>Registered:</td>
<td align="center">Yes<img src="../../Images/shim.gif" border="0" width="22" height="0">No</td>
</tr>
</table>
<br> <br></td>
</tr>
</table></td>
</tr>
<tr>
<td valign="top" class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td width="325" class="FormInnerRowRightBorder"> Circle if Dictated:<img src="../../Images/shim.gif" border="0" width="30" height="1">Fellow/
Resident<img src="../../Images/shim.gif" border="0" width="30" height="1">Attending</td>
<td width="325">Copy to: <input name="fellow222" type="checkbox" id="fellow223">
referring M.D.: ________________________<br> <img src="../../Images/shim.gif" border="0" width="50" height="1">
<input name="fellow2222" type="checkbox" id="fellow2222">
other: _______________________________</td>
</tr>
</table></td>
</tr>
<tr >
<td class="FormOuterTableRow"><table width="650" border="0" cellspacing="0" cellpadding="4">
<tr>
<td><span class="blackBoldText">Signatures</span><br></td>
<td colspan="2"> </td>
</tr>
<tr>
<td width="100"><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">Fellow:
</span></td>
<td width="350"><span class="blackBoldText">________________________________________________</span></td>
<td width="200"><span class="blackBoldText">Date:____/____/____</span>
</td>
</tr>
<tr>
<td><span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="6" height="1">NP
/ PA: </span></td>
<td><span class="blackBoldText">________________________________________________</span></td>
<td><span class="blackBoldText">Date:____/____/____</span> </td>
</tr>
<tr>
<td colspan="3"><table width="642" cellpadding="0" cellspacing="0" class="FormInnerTableBlackTopRow">
<tr>
<td><table width="642" border="0" cellspacing="0" cellpadding="4">
<tr>
<td><span class="blackBoldText">
<input name="fellow" type="checkbox" id="fellow">
</span>I personally performed or was physically present during the <strong>key portions</strong> of the procedure today. <br> <span class="blackBoldText"><img src="../../Images/shim.gif" border="0" width="1" height="20">MD
/ Attending: ________________________________________________
<img src="../../Images/shim.gif" border="0" width="24" height="1">Date:____/____/____</span>
<span class="blackBoldText"> </span></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
<tr >
<td height="14" align="center" valign="bottom" class="blackBoldText">GU06<img src="../../Images/shim.gif" border="0" width="45" height="1">U10<img src="../../Images/shim.gif" border="0" width="45" height="1">CMIC
Approval Date: 6/03<img src="../../Images/shim.gif" border="0" width="45" height="1">rev:08/08/06<img src="../../Images/shim.gif" border="0" width="45" height="1">Page
3 of 3<img src="../../Images/shim.gif" border="0" width="45" height="1">B/02.070.<span class="blackBoldTextSmall">06</span></td>
</tr></table>
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