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["　　　　　　　　　　　　　　　診　療　情　報　提　供　書　　　　　　　　　　　　　　（提出用）"]
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[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"作成日",null,null,null,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,null,"女"]
["紹介先医療機関名"]
["公立藤岡総合病院"]
[null,null,null,null,null,"科",null,null,null,null,null,null,"先生"]
["診療及び検査希望日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"紹介元医療機関"]
[null,null,"月",null,null,"日","（　　）",null,null,"午前",null,"午後",null,null,null,"診療科名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"明治"]
[null,null,"月",null,null,"日","（　　）",null,null,"午前",null,"午後",null,null,null,"医師氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正"]
["※ 公立藤岡総合病院受診歴",null,null,null,null,null,null,null,null,"無",null,"有","患者No",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭和"]
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["フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,"生年月日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"令和"]
["患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
["住　所",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年齢",null,null,null,null,"歳"]
["電話番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"携帯番号"]
[]
["診断名（傷病名）"]
[]
[]
["薬剤アレルギー",null,null,null,null,"無",null,null,"有","（",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
["感染症有無",null,null,null,null,"無",null,null,"有",null,null,"HBV",null,null,"HCV",null,null,"HIV",null,null,"ワ氏"]
[]
["症状及び治療経過・検査結果等"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["添付資料",null,null,null,null,"無",null,null,"有","（",null,"X-P",null,null,"ＣＴ",null,null,"ECG",null,null,"検査データ",null,null,null,"内視鏡フィルム）"]
["返　　　却",null,null,null,null,"要",null,null,"不要"]
["備　　　考"]
[]
["公立藤岡総合病院",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"患者支援センター（直通）"]
["〒375-8503　群馬県藤岡市中栗須813番地1",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"TEL：０２７４-２２-６０３９"]
["TEL ：　０２７４-２２-３３１１　（代表）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX：０２７４-２４-７００２"]