EK- 1/B

 

KAMU PERSONELİ VE BUNLARIN EMEKLİLERİNİN YURTDIŞINDA TEDAVİLERİNE İLİŞKİN SAĞLIK KURULU RAPORU

 

Raporu Düzenleyen Kurum:                                                                                                 

                                                                                                                                            Fotoğraf

 


Rapor Tarihi:......../......./............        Rapor No:........................

Adı Soyadı                   :............................................................................................................................

Doğum Yeri/Tarihi      : ...........................................................................................................................

Çalıştığı Kurum           : ...........................................................................................................................

Görevi                          :............................................................................................................................

Kurum Sicil No           : ............................................................................................................................

T.C. Kimlik No (Mem): .................................................T.C.Kimlik No (Has):.......................................

Yakınlık Derecesi        : ...........................................................................................................................

Dosya No                     :......................................Protokol No:.................................................................

Ana Bilim Dalı/Bilim Dalı/Klinik: ..........................................................................................................

Klinik Bulgular:........................................................................................................................................

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Röntgen Ve Laboratuvar Bulguları:.........................................................................................................

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Tanı:

Önerilen Tedavi:

Önerilen Tedavinin

Türkiye’de Yapılamama Gerekçeleri:

 

 Karar*:

Gideceği Ülke:                              Şehir:                     Sağlık Kurumu:

Sağlık Kurulu Üyeleri

 

 

 

                                                                                            Başhekim

 

                                                                                              İMZA

                                                                                            MÜHÜR

 

*Bu bölümde tedavi süresi ve tedavi sırasında hastaya refakat gerekli olup olmadığı açıkça belirtilecektir.