Localitatea __________ Unitatea sanitara_________________
Data ntocmirii 20_luna__ziua__
BILET DE IEIRE DIN SPITAL
Bolnavul: numele_______________ prenumele __________________ Sexul M / F n vrst de _________ ani, cu domiciliul n: judeul _____________ localitatea _________________________ str. _______________________________________nr. ______________ Dispensar medical _________________________________________ A fost internat n secia _____________________________________ cu diagnosticul: ___________________________________________ ________________________________________________________ de la _______________________pn la ______________________ i iese n stare _____________________________________________ ESTE/ NU ESTE purttor de germeni: felul ______________________ _____________________________tipul _________________________