Judeul

Localitatea __________

Data ntocmirii20_luna__ziua__

Unitatea sanitara_________________BILET DE IEIRE DIN SPITALBolnavul: numele_______________ prenumele __________________Sexul M / F n vrst de _________ ani, cu domiciliuln: judeul _____________ localitatea _________________________str. _______________________________________nr. ______________Dispensar medical _________________________________________A fost internat n secia _____________________________________cu diagnosticul: ___________________________________________________________________________________________________

de la _______________________pn la ______________________i iese n stare _____________________________________________ESTE/ NU ESTE purttor de germeni: felul ______________________

tipul _________________________

REZUMATUL FOII DE OBSERVAIE (epicriz, indicaii)