Mu 44

(Ban hnh km theo Quyt nh s 617/Q-UBND-HC

ngy 28 thng 6 nm 2013 ca Ch tch UBND tnh ng Thp)

N V.......
KHOA/ T/ PCT YHCT

N THUC

S: ............ /..........

N V.......
KHOA/ T/ PCT YHCT

N THUC

S: ............ /..........

H tn bnh nhn: .................................................................................Gii tnh:.......

Ngy sinh:........./........../............... Ngh nghip.........................................................
a ch:.................................................................................................................................
S BHYT:..........................................................Thi hn: ngy.......thng......nm..............
Ni ng k ban u:...........................................................................................................
Chn on: ...........................................................................................................................
Th bnh: .............................................................................................................................

H tn bnh nhn: .................................................................................Gii tnh:.......

Ngy sinh:........./........../............... Ngh nghip.........................................................
a ch:.................................................................................................................................
S BHYT:......................................................... Thi hn: ngy.......thng......nm..............
Ni ng k ban u:...........................................................................................................
Chn on: ...........................................................................................................................
Th bnh: .............................................................................................................................

Phng tr

Phng tr

TT

Tn ch nh

S lng/VT

Ghi ch

Hng dn:...............................................................................................................
.....................................................................................................................................
King k:..................................................................................................................
Ti khm:......................

...................,ngy ..... thng ..... nm ............

Lng y, Y, Bc s khm bnh
(k tn v ghi r h v tn)

TT

Tn ch nh

S lng/VT

Ghi ch

Hng dn:...............................................................................................................
.....................................................................................................................................
King k:..................................................................................................................
Ti khm:......................

...................,ngy ..... thng ..... nm ............

Lng y, Y, Bc s khm bnh
(k tn v ghi r h v tn)