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NON COMPILARE QUESTO RIQUADRO
DATA RICEZIONE _________________________________________
CARDIOLOGIE APERTE - 23 OTTOBRE 2005
DATI U.O. DI CARDIOLOGIA:
Ospedale ___________________________________________________________________________________________________________________________________________
Reparto ______________________________________________________________________________________________________________________________________________
Direttore _____________________________________________________________________________________________________________________________________________
Telefono ________________________________________________________________________ Fax ______________________________________________________________
Indirizzo _____________________________________________________________________________________________________________________________________________
Città __________________________________________________________________________________________________________________________________________________
E-mail ________________________________________________________________________________________________________________________________________________
Sito web ospedale ________________________________________________________________________________________________________________________________
Direttore Generale ________________________________________________________________________________________________________________________________
Direttore Sanitario _________________________________________________________________________________________________________________________________
Esatta dicitura Az. Osp. _________________________________________________________________________________________________________________________
Indirizzo _____________________________________________________________________________________________________________________________________________
DATI PERSONALI RICHIEDENTE
Nome ________________________________________________________________________________________________________________________________________________
Telefono/Cellulare _________________________________________________________________________________________________________________________________
E-mail ________________________________________________________________________________________________________________________________________________
Inviare via fax: 055582756
45
