Sở Y tế: ..............................
BV: ....................................
Phiếu chiếu/ chụp X-Quang
(lần thứ .................)
MS:08/BV-02
Số: ................................
- Họ tên người bệnh: .............................................................. Tuổi: ........................... Nam/Nữ
- Địa chỉ: ................................................................................................ .................................................................................
- Khoa: ....................................................................................... Buồng: .....................................Giường: ............................
- Chẩn đoán: ............................................................................................................................................................................
Yêu cầu chiếu/ chụp
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Ngày ....... tháng ....... năm .............
Bác sĩ điều trị
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![](data:image/png;base64,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)
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Ngày ....... tháng ....... năm .............
Lời dặn của BS chuyên khoa: Bác sĩ chuyên khoa
Họ tên: ...........................................