16.2_condica De Prescriptii Medicamente Si Materiale Sanitare

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Judeţul……………………………………………………….

Data a a a a

l l z z

Localitatea……………………………………………………. Unitatea sanitară……………………………………………… Secţia………………………………………………………….

1

Cantitatea

Numele şi prenumele bolnavului vîrsta

PRESCRIP ŢIA

U/M

Nr.crt.

CONDICĂ DE PRESCRIPŢII MEDICAMENTE ŞI MATERIALE SANITARE

2

3

4

Cerută

Eliberată

5

6

Preţ unitar

Valoarea totală

7

8

Total lei Semnătura şi parafa medicului,

Am eliberat,

Am primit,

Ştampila 16.2; A4; t1

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