Наименование учреждения: г.Томск, ул.

Белинского 15,
ООО «Скорая наркологическая помощь» офис 209, тел. 22-30-02
Лицензия N ЛО-70-01-000969

Выписка
из истории болезни № ________

1. Фамилия, имя, отчество больного

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2. Возраст больного
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3. Домашний адрес
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4. Дата и время проведения лечебных мероприятий
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5. Диагноз (основное заболевание, сопутствующее заболевание)
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6. Краткий анамнез, состояние больного на момент осмотра, течение болезни
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7. _ Лечение
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8. Рекомендации
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«____»_________________20___г мп Врач ___________________