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["　　診療情報提供書（検査依頼）  　　　　"]
[null,null,null,null,null,null,null,null,null,null,null,"年　　月　　日"]
[]
[" ご紹介先",null,null,null,null,null,"ご紹介元"]
[]
[null,"【公立八鹿病院】",null,null,null,null,null,null,"【　 　　　　　　　　    　】"]
[null,null,null,null,null,null,null,null,"　　    　　　　 　先生"]
[]
[null,null,null,null,null,null,null,null,null,"TEL"]
[null,null,null,null,null,null,null,null,null,"FAX"]
[]
[]
[" 患者様情報　",null,null,null,"　（八鹿病院のカルテ番号がお分かりになればご記入ください　<No.　　　　　　   　　　　　　> ）"]
[null,"フリガナ",null,null,null,null,null,"生年月日"]
[null,"氏名",null,null,null,null,null,null,null,null,null,"　　　年　　月　　日（　　歳）"]
[null,"住所",null,"〒",null,null,null,"連絡先",null,"TEL",null,"　　　-　　　　　-"]
[null,null,null,null,null,null,null,null,null,"携帯",null,"　　　-　　　　　-"]
[null,"保険情報"]
[]
[" 目的、診断名及び検査部位（できるだけ詳しくお願いします）"]
[null,"検査予約日"]
[null,"　　　　　　年　　　　月　　　　日（　　　　）　　　　　　AM　・　PM　　　　："]
[]
[]
[null,"目的"]
[]
[]
[]
[null,"診断名"]
[]
[]
[]
[null,"CT"]
[]
[]
[]
[]
[null,null,null,null,"造影剤（          ・            ）"]
[null,"MRI"]
[]
[]
[]
[null,"備考"]
[]
[]
[]
[]
[null,"＊薬剤アレルギー（　　　 ・ 　　　）　　　　＊妊娠の可能性（ 　　　　・　　　　 ）"]
[]
[]
[null,null,null,null,null,null,null,"患者様のご都合のつなかい日がありましたら、"]
[null,"第1希望",null,null,"月　　　　日　　　　　曜日",null,null,"あらかじめお教えください"]
[null,"（決定日）"]
[]
[null,"第2希望　",null,null,"月　　　　日　　　　　曜日"]
[]
[null,null,null,null,"　　（緊急性の有無　　　　　　　　　）      "]
[]
[null,"□ いつでも可"]
[null,null,null,"（患者予約*予約方法の説明書もお渡しください）"]
[]
[]
[]
[null," 〒667-8555   兵庫県養父市八鹿町八鹿1878番地1",null,null,null,null,null,null,"公立八鹿病院　地域医療連携室"]
[null,null,null,null,"TEL 079-662-5555（代表）　FAX 079-662-3143（直通）"]
[null,"【受診日までにFAXをお願いします】"]