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賢德醫院申請病歷摘要、加開診斷書
填表完成後將以電話通知領取,現場繳費、如為代申請,因個人隱私,為保障病人權益,
請攜帶<雙方>身分證及健保卡正本確認身份。 若申辦證件不齊全或為影印本者恕不受理。
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申請日期
*
Your answer
姓名 【 本人申請】
Your answer
姓名 【 代理人申請】
Your answer
出生年月日
*
MM
/
DD
/
YYYY
身分證字號
*
Your answer
聯絡電話
*
Your answer
申請期間(年月日~年月日)
*
Your answer
申請文件
*
出院病歷摘要
護理記錄
門診記錄
加開診斷書(備註:如是初次申請診斷書,需醫師看診時間,方能開立)
胃鏡報告
腸鏡報告
超音波
病理切片
Other:
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申請用途
*
轉診
保險
訴訟
參考
行政相驗
重病申請
Other:
E-mail(沒有信箱可不用填寫)
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如有其他問題請填寫:
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