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    William Chi Cen
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    formato similares referencia

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    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
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    436 views1 page

    Formato de Referencia

    Uploaded by

    William Chi Cen
    formato similares referencia

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    FUNDACION BEST A.C.

    FORMATO DE REFERENCIA

    DATOS DEL PACIENTE


    FECHA DE REFERENCIA:___________________
    NOMBRE DEL PACIENTE: ________________________________________________________
    SEXO: __________
    EDAD: ______________
    DIAGNOSTICO: ____________________
    UNIDAD A LA QUE SE REFIERE: ________________________________________________
    URGENCIA: SI ( ) NO ( ) SERVICIO AL QUE SE REFIERE: _______________________

    DATOS DEL MEDICO


    NOMBRE DEL MEDICO: _________________________________________________________
    CEDULA PROFESIONAL: ____________________ UNIVERSIDAD DE EGRESO: __________
    UNIDAD DE LA QUE REFIERE: ___________________________________________________
    DIRECCION DEL CONSULTORIO: ________________________________________________

    RESUMEN CLINICO
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    DIAGNOSTICO DE REFERENCIA:
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    TERAPEUTICA EMPLEADA:
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    MOTIVO DE REFERENCIA:
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    ________________________________________________________________________________________
    __________________________________________________________
    NOMBRE Y FIRMA DEL MEDICO

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