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DECLARATIE PE PROPRIE RASPUNDERE

Subsemnatul (a) .............................................. domiciliat in .....................................................

Posesor al BI/CI seria .... nr ..........................declar pe propria raspundere ca pe perioada

internarii in SCJU Arad nu voi beneficia de servicii medicale in nici o alta unitate sanitara, de
stat sau privata.

Arad...................... Semnatura

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