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NON COMPILARE QUESTO RIQUADRO
DATA RICEZIONE _________________________________________
CARDIOLOGIE APERTE - 30 SETTEMBRE 2007
DATI U.O. DI CARDIOLOGIA:
Ospedale ________________________________________________________________________________________________________________________________________
Reparto ___________________________________________________________________________________________________________________________________________
Direttore __________________________________________________________________________________________________________________________________________
Telefono __________________________________________________________________________ Fax _________________________________________________________
Indirizzo ___________________________________________________________________________________________________________________________________________
Città ________________________________________________________________________________________________________________________________________________
E-mail ospedale __________________________________________________________________________________________________________________________________
Sito web ospedale ______________________________________________________________________________________________________________________________
Direttore Generale _______________________________________________________________________________________________________________________________
Direttore Sanitario________________________________________________________________________________________________________________________________
Esatta dicitura Az. Osp. _______________________________________________________________________________________________________________________
Indirizzo ___________________________________________________________________________________________________________________________________________
DATI PERSONALI RICHIEDENTE
Nome ______________________________________________________________________________________________________________________________________________
Telefono/Cellulare________________________________________________________________________________________________________________________________
E-mail ______________________________________________________________________________________________________________________________________________
Inviare via fax: 055582756
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