Documente Academic
Documente Profesional
Documente Cultură
Gheorghita Andrei
Subsemnatul (a) __________________________________________________________
Scobinti,
Scobinti, Iasi, Romania
domiciliat () n ________________________________________________________________
legitimat () cu B.I./C.I. seria ____ nr. ____________, n calitate de:
Gheorghita Andrei
1. Pacient () prezentat () __________________________________________________
Gheorghita Andrei
2. Reprezentant legal al _____________________________________________
n vrst
27
de ____________
prezentat ()__________________________________________________
3. Aparintor (so/soie, frate/sor, ____________________________) al pacientului (ei)
prezentat ()__________________________________________________, declar urmtoarele
date:
Vor completa doar persoanele de sex feminin aflate la vrsta fertil (14-55 de ani).
Semntura declarant2
28-03-2015
______________