Mu 01

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

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

CNG HO X HI CH NGHA VIT NAM

c lp T do Hnh phc

.............................. 1, ngy....... thng..... nm 20.....

N NGH
Cp chng ch hnh ngh khm bnh, cha bnh
Knh gi: S Y t tnh ng Thp.
H v tn:................................................................................................................
Ngy, thng, nm sinh: ...........................................................................................
a ch ng k h khu thng tr:2 .....................................................................
.................................................................................................................................
Giy chng minh nhn dn s: ..................................., Cp ngy......../....../..........
Ni cp:.....................................
in thoi:.............................................. Email (nu c): .....................................
Vn bng chuyn mn: 3..........................................................................................
nh km theo theo n ny gm cc giy t sau:
1. Bn sao c chng thc vn bng chuyn mn.
2. Giy xc nhn qu trnh thc hnh khm bnh, cha bnh.
3. S yu l lch.
4. Phiu l lch t php (do S T php cp).
5. Hai nh chn dung mu (nn trng) 04cm x 06 cm.
Knh ngh S Y t xem xt v cp chng ch ti c hnh ngh khm
bnh, cha bnh./.
NGI LM N
(K v ghi r h, tn)

1. a danh.
2. Ghi r a ch theo ni ng k thng tr hoc tm tr.
3. Vn bng chuyn mn ghi theo i tng: Bc s, Y s, iu dng vin, H sinh vin, K thut vin, Lng
y, Giy chng nhn bi thuc gia truyn hoc Giy chng nhn phng php cha bnh gia truyn.