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[null,"様式２",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"紹介元医療機関保管用/患者持参用"]
[null,null,null,null,null,null,"中津川市民病院 CT・MRI予約申込書"]
[]
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[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"申込年月日",null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,"Fax送付内容　：　本用紙"]
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[null,null,null,null,null,"中津川市民病院　医療連携室",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Fax：0573-62-4012"]
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[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,null,null,null,null,"↑お間違えのないようにお願いいたします。"]
[null,null,null,null,"紹介元医療機関の\n名称",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,null,null,"　医師氏名"]
[]
[]
[null,null,null,null,"　電話番号",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,null,null,"Fax番号"]
[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,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,"ふ　り　が　な",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,"生年月日"]
[null,null,null,null,"　患者様氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"様",null,"性別："]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　年",null,null,null,null,"月",null,null,null,"日"]
[null,null,null,null,"　患者様住所",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,null,null,"患者様\n電話番号"]
[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,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,null,"疑われる病名（症状）\n又は検査目的"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"読影希望　"]
[]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（禁忌事項）"]
[]
[null,null,null,null,"（必ず記入してください）"]
[null,null,null,null,"依頼検査項目　　　　",null,null,"　　　該当項目の□にチェック","　　を入れてください。"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（その他：　　　　　　　　　　）",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,null,null,null,"（その他：　　　　　　　　　　）"]
[]
[]
[]
[]
[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,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,null,null,null,null,null,null,null,"（その他　　　　　　　　）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　　　　　　　　　　　　　",null,null,null,null,"（その他　　　　　　　　）"]
[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,null,null,null,null,null,null,null,null,"MRI検査の場合"]
[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,null,null,null,null,null,null,null,null,"チェック項目"]
[]
[null,null,null,null,"　検査希望日",null,null,null,null,null,null,null,null,null,"第1希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"頃（検査時間は基本的に15：00頃です）"]
[null,null,null,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",null,null,null,"時",null,null,"分"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"第2希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"頃（検査時間は基本的に15：00頃です）"]
[null,null,null,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",null,null,null,"時",null,null,"分"]
[null,null,null,null,"　都合の悪い日",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,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,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,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,"年",null,null,"月",null,null,"日",null,null,null,null,null,null,null,null,null,null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,"※平日午前8時30分～午後6時00分までは30分以内に回答いたします。"]
[null,null,null,null,null,null,"午後6時00分以降は翌日午前中、金曜日午後6時00分以降・土・日・休日は、休み明けの午前中に回答させていただきます。"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（※　以下の部分を切り離して患者様にお渡し下さい。）"]
[]
[]
[null,null,null,null,null,"返信",null,null,null,null,null,null,null,null,null,"中津川市民病院CT・MRI検査予約票"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,"↓紹介医療機関様は記入しないで下さい。"]
[null,null,null,null,null,"ふ　り　が　な",null,null,null,null,null,null,null,null,"　"]
[null,null,null,null,"　患者様氏名",null,null,null,null,null,null,null,null,null,"様　　　"]
[]
[null,null,null,null,"　検査名",null,null,null,null,null,null,null,null,null,"□　CT（単純検査）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□　MRI（単純検査）"]
[]
[]
[null,null,null,null,"　検査予約日",null,null,null,null,null,null,null,null,null,"年　　　月　　　日　　　　　　　　時　　　分"]
[]
[]
[null,null,null,null,null,null,null,null,null,"１．　「連携病院からの紹介で中津川市民病院でCT・MRI検査をお受けになる方へ」の用紙をよく読んでください。"]
[null,null,null,null,null,null,null,null,null,"検査当日、中津川市民病院にお越しいただいたら"]
[]
[null,null,null,null,null,null,null,null,null,"１．　「紹介状受付」受付窓口②番までお越し下さい。"]
[]
[null,null,null,null,null,null,null,null,null,"２．　「紹介状受付」受付窓口②番にて下記のものをご提示してください。その後、案内票をお渡しいたします。"]
[null,null,null,null,null,null,null,null,null,null,null,null,"①　中津川市民病院CT・MRI検査予約票",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"②　中津川市民病院 CT・MRI予約申込書"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（この紙）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（依頼施設からの封筒内）"]
[null,null,null,null,null,null,null,null,null,null,null,null,"③　保険証",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"④　中津川市民病院の診察券（あれば）"]
[]
[null,null,null,null,null,null,null,null,null,"３．　検査当日ご不明な点がありましたら、職員に声をかけてください。"]
[null,null,null,null,null,"※検査予約状況により、予約時間より多少遅れる場合がありますのでご承知下さい。"]
[null,null,null,null,null,"※予約の日時変更を希望される場合は、医療連携室（0573-62-4011）まで早めにお電話ください。"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"総合病院中津川市民病院　　　　　　　　医療連携室"]