FIA PERSONAL A MEDICULUI DENTIST

Nume ______________________________ Prenume ____________________________________

Iniiala tatlui ___ Numele de familie anterior __________________________________
Cod numeric personal : _ _ _ _ _ _ _ _ _ _ _ _ _
Cetenia ____________ , Act identitate: C.I. seria ___ nr. ______ , elib.Pol.________/ data ______
Data naterii __________ , Adresa de domiciliu : _________________________________________
Adresa de e-mail : ___________________________
Telefoane : Domiciliu ____________ , Cabinet ________________ , Mobil _________________
Universitatea absolvit : _____________________ Localitatea _______________ara___________
Facultatea : _________________________ , Secia : ______________________________________
Diploma seria ____ nr. ___________ ,

Nr. ____ i data elib. ______________ , Promoia _____

Medic rezident : _________________________ din data de ________ pn n data de ___________

Specialitatea medical : _______________________ , data confirmrii n _____________________
Specialitatea medical : _______________________ , data confirmrii n _____________________
Gradul universitar _____________________ din data de __________ la Univ. _________________
Doctoratul n _________________________ din data de __________ la Univ. _________________
Competene medicale _______________________________________________________________
Supraspecializri __________________________________________________________________
Locuri de munc : _________________________________________________________________
Adresa cabinet :___________________________________________________tel. _____________
Medic titular cabinet : ______________________________________________________________
Medici angajai : __________________________________________________________________
Prin semnarea prezentei fie medicale mi dau consimmntul ca datele mele personale s intre n
baza de date a Colegiului Medicilor Dentisti din Romnia Colegiul Medicilor Dentisti Cluj,
conform Legii nr.677 / 2001. La cererea mea explicit C.M.D.R. se oblig s actualizeze , tearg
sau s m informeze despre datele personale procesate .
Data completrii : ____________ ,

Semntura : _____________ ,

Parafa ______________