ANEXA 7*)

*) Anexa nr. 7 este reprodusa in facsimil.

Cabinet medical din ambulatoriul de specialitate/spital..........

Medic............................................................
Specialitatea....................................................
Contract incheiat cu CAS.................. Nr. contract.........
SCRISOARE MEDICALA

Domnului/doamnei Dr. (adresa cabinetului medical) _________________________

___________________________________________________________________________
Stimate(a) coleg(a), va informam ca pacientul dumneavoastra
_________________________________________________ nascut la data ______________, CNP
_____________________, a fost consultat in serviciul nostru la data de ______________
Diagnosticul: _____________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
Anamneza: - motivul prezentarii ___________________________________________
___________________________________________________________________________
- factori de risc _______________________________________________
___________________________________________________________________________
Examen clinic: - general __________________________________________________
___________________________________________________________________________
- local ____________________________________________________
___________________________________________________________________________
Examene de laborator: - cu valori normale _________________________________
___________________________________________________________________________
- cu valori patologice ______________________________
___________________________________________________________________________
Examene paraclinice: EKG __________________________________________________
ECO __________________________________________________
Rx ___________________________________________________
Alte _________________________________________________
___________________________________________________________________________
Tratament recomandat: _____________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
___________________________________________________________________________
______________________________________________________________________________
| Unitate judeteana de diabet zaharat: | |
|______________________________________|_______________________________________|
| Nr. inregistrare a asiguratului: | |
|______________________________________|_______________________________________|
Data:
Semnatura si parafa medicului:

Calea de transmitere: - prin asigurat

- prin posta..............."