Cabinet medical din ambulatoriul de specialitate/spital ........
Medic ..........................................................
Specialitatea ..................................................
Contract incheiat cu CAS ...... Nr. contract ...................
SCRISOARE MEDICALA
Domnului/doamnei Dr.(adresa cabinetului medical) ________________
_________________________________________________________________
Stimate(a) coleg(a), va informam ca pacientul
dumneavoastra _________________________________ nascut la data
__________, CNP ______________, a fost consultat in serviciul nostru la
data de __________________
Diagnosticul: ______________________
______________________
______________________
______________________
Anamneza: - motivul prezentarii ____________________________________________
____________________________________________________________________________
- factori de risc ________________________________________________
____________________________________________________________________________
Examen clinic: - general ___________________________________________________
____________________________________________________________________________
- local _____________________________________________________
____________________________________________________________________________
Examen de laborator: - cu valori normale ___________________________________
____________________________________________________________________________
- cu valori patologice ________________________________
____________________________________________________________________________
Examene paraclinice: EKG ___________________________________________________
ECO ___________________________________________________
Rx ____________________________________________________
Alte __________________________________________________
____________________________________________________________________________
Tratament recomandat: ______________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
____________________________________________________________________________
┌────────────────────────────────────────┬──────────────────────────────────┐
│Unitate judeteana de diabet zaharat: │ │
├────────────────────────────────────────┼──────────────────────────────────┤
│Nr. Inregistrare a asiguratului: │ │
└────────────────────────────────────────┴──────────────────────────────────┘
Data:
Semnatura si parafa medicului:
Calea de transmitere: - prin asigurat
- prin posta ............"