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2019/1/19 高雄榮總先天性結構性心臟病醫學中心醫療講座暨病友會報名表
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姓名
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生日
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MM
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DD
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YYYY
身分證字號
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聯絡電話
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通訊地址
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E-mail
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參加身分
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病童
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是否攜帶家屬
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是，請於下方填寫所有參加者姓名
否，可略過
其他參加人員姓名
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