Cabinet medicaldin ambulatoriu de specialitate/spital.....................

Contract ncheiat cu:

CAS
CAS-T
OPSNAJ
Eurocard

Nr. contract ......

Acorduri internaionale

SCRISOARE MEDICAL
Domnului / doamnei Dr. ____________________________
Stimate () coleg(), v informm c pacientul dumneavoastr__________________________________
CNP _____________________________ asigurat la :
OPSNAJ
Casa. j
Casa-T
Eurocard
Acorduri internaionale
a fost consultat n serviciul nostru la data de____________________
Diagnosticcul : COD (CIM 10)
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Anamneza:- factori de risc _________________________________________________________________

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Examen clinic: __________________________________________________________________________
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Examene de laborator efectuate :____________________________________________________________
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- din care cu valori patologice_______________________________________________________________
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Examene paraclinice: EKG_________________________________________________________________
ECO __________________________________________________________________________________
Rx ____________________________________________________________________________________
Alte ___________________________________________________________________________________
Tratament recomandat:____________________________________________________________________
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AM ELIBERAT REETA PENTRU PERIOADA ________________________________
DATA CONTROLULUI URMTOR:

1. n ambulatoriul de specialitate data __________________ ora ________________

2. La medicul de familie
- data __________________ ora ________________
Nr. nregistrare a asiguratului :
Data :
Semntura i parafa medicului :

29.5; A4; t1

Calea de transmitere: - prin asigurat

29.5; A4; t1

prin pot