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Ministerul Sntii al Republicii Moldova

denumirea instituiei

DOCUMENTAIE MEDICAL
Formular
nr. 119-1/e

Aprobat de MS RM
nr. 828 din 31.10. 2011
PM

ADEVERIN
DE CONFIRMARE A SOLICITRII ASISTENEI MEDICALE DE URGEN


____ ______________________ 20 ____ la ora _______ _______ min.

.
a fost preluat solicitarea nr. _________________________ n serviciul de asisten medical


urgent 903 de la ceteanul (ca) ______________________________________________
903 ()
__________________________________________________________________________
Adresa pacientului ___________________________________________________________

__________________________________________________________________________
Motivul solicitrii ___________________________________________________________

Echipa de AMU a plecat la ora _______ _______ min., medicul _________________

.,
felcerul ___________________________ la bolnavul _______________________________


A fost stabilit diagnosticul _____________________________________________________

__________________________________________________________________________
Ajutorul medical acordat ______________________________________________________

__________________________________________________________________________
__________________________________________________________________________
Pentru prezentare conform cerinei nr. _____________ din ____________________________

__________________________________________________________________________
denumirea instituiei

eful seciei operative a staiei de AMU