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{"sheet":"受診予約依頼票","index":0,"n_rows":85,"n_cols":34,"rows_kept":85,"cut":false,"hidden":false,"merged":[[73,29,73,32],[75,1,75,4],[75,5,75,34],[71,1,71,4],[71,5,71,34],[72,1,72,4],[72,16,72,17],[73,1,74,4],[73,14,73,15],[74,14,74,15],[72,7,72,9],[72,18,72,20],[72,23,72,25],[72,13,72,14],[72,11,72,12],[72,5,72,6],[73,5,73,6],[74,5,74,6],[66,33,66,35],[66,29,66,31],[66,25,66,27],[67,28,67,30],[67,32,67,34],[66,1,66,11],[66,12,66,22],[65,5,65,22],[65,23,65,34],[65,1,65,4],[67,1,67,4],[67,5,67,13],[67,14,67,17],[67,18,67,26],[55,15,55,16],[55,18,55,19],[55,22,55,25],[64,1,64,4],[64,5,64,6],[62,1,63,4],[62,16,63,18],[62,23,63,31],[61,1,61,4],[61,21,61,34],[62,5,63,15],[61,16,61,18],[61,5,61,15],[56,3,56,9],[56,22,56,30],[55,11,55,14],[64,7,64,11],[64,12,64,34],[33,22,34,34],[34,0,35,13],[47,8,47,9],[47,15,47,16],[47,23,47,24],[48,8,48,9],[48,15,48,16],[48,23,48,24],[41,17,42,21],[41,22,42,34],[45,8,45,9],[45,15,45,16],[45,23,45,24],[46,8,46,9],[46,15,46,16],[46,23,46,24],[19,1,19,6],[19,7,19,34],[21,1,21,6],[16,1,16,6],[16,7,16,8],[17,1,17,6],[17,7,17,34],[18,1,18,6],[18,7,18,34],[20,1,20,6],[20,7,20,34],[21,7,21,34],[16,9,16,19],[13,1,13,6],[13,7,13,34],[14,1,14,6],[14,7,14,34],[15,1,15,6],[15,7,15,19],[15,21,15,34],[9,1,9,6],[9,7,9,34],[10,1,10,6],[10,7,10,34],[12,1,12,6],[12,7,12,34],[6,1,6,6],[6,7,6,34],[7,1,7,6],[7,7,7,34],[8,1,8,6],[8,7,8,34],[1,1,1,2],[3,1,3,6],[3,7,3,19],[3,21,3,34],[5,1,5,6],[5,7,5,34],[49,21,49,29],[25,1,25,34],[28,27,28,34],[29,0,31,12],[31,17,32,21],[31,22,32,34],[55,26,55,27],[55,29,55,30],[56,11,56,12],[55,1,55,3],[55,4,55,5],[55,7,55,8],[49,8,49,9],[49,15,49,16],[35,17,36,21],[35,22,36,34],[36,0,37,13],[37,17,38,21],[37,22,38,34],[38,0,39,13],[39,17,40,21],[39,22,40,34],[32,0,33,12],[33,17,34,21]]}
[]
[null,"【患者情報】",null,null,"●下記へ入力されましたら受診予約依頼票および紹介状へも入力されます"]
[]
[null,"申 込 日",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"※入力例　6/8 → 令和3年6月8日"]
[]
[null,"医療機関名"]
[null,"住　　所"]
[null,"医 師 名"]
[null,"電話番号"]
[null,"FAX番号"]
[" ","担 当 者"]
[]
[null,"ふりがな"]
[null,"患者氏名"]
[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,"※入力例　h14/6/8 → 平成14年6月8日"]
[null,"郵便番号",null,null,null,null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,"※－は不要です"]
[null,"住　　所"]
[null,"電話番号"]
[null,"自宅以外の連絡先\n（携帯等）"]
[null,"保険証番号"]
[null,"記号・番号"]
[]
[]
[]
[null,"受診予約依頼票（FAX送信票）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,{"$f":"H4","v":"00:00:00"}]
["社会医療法人北斗"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関名",null,null,null,null,{"$f":"H6","v":0}]
["北斗病院 ／ 北斗クリニック"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住　所",null,null,null,null,{"$f":"H7","v":0}]
["患者サポートセンター 地域医療連携室行"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医 師 名",null,null,null,null,{"$f":"H8","v":0}]
["FAX番号　0155-47-3083"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,null,{"$f":"H9","v":0}]
["受付時間　平日9:00～17:00、土曜9:00～12:00"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX番号",null,null,null,null,{"$f":"H10","v":0}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者名",null,null,null,null,{"$f":"H11","v":0}]
[]
["【受診希望科】"]
[]
[null,"□","脳神経外科",null,null,null,null,null,"□",null,"消化器外科",null,null,null,null,"□",null,"心臓血管外科",null,null,null,null,null,"□",null,"整形外科・リウマチ科"]
[null,"□","脳神経内科",null,null,null,null,null,"□",null,"消化器内科",null,null,null,null,"□",null,"循環器内科",null,null,null,null,null,"□",null,"耳鼻咽喉科・頭頸部外科"]
[null,"□","乳腺外科",null,null,null,null,null,"□",null,"眼科",null,null,null,null,"□",null,"総合診療科",null,null,null,null,null,"□",null,"核医学診断科（PET）"]
[null,"□","歯科口腔外科",null,null,null,null,null,"□",null,"皮膚科",null,null,null,null,"□",null,"泌尿器科",null,null,null,null,null,"□",null,"放射線治療科"]
[null,"□","リンパ浮腫外来",null,null,null,null,null,"□",null,"甲状腺外来",null,null,null,null,"□",null,"その他（　　　　　　　　　　）",null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[]
[]
["【受診希望日】"]
[]
[null,"（第１希望）",null,null,null,null,"月",null,null,"日",null,"（第２希望）",null,null,null,null,null,"月",null,null,"日",null,"（第３希望）",null,null,null,null,null,"月",null,null,"日"]
[null,null,"□","受診希望日なし",null,null,null,null,null,null,null,"□",null,"都合の悪い日･曜日など（　　　　　             　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"）"]
[]
[null,"【患者情報欄】"]
[]
[]
[null,"ふりがな",null,null,null,{"$f":"H13","v":0},null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"　生 年 月 日"]
[null,"患者氏名",null,null,null,{"$f":"H14","v":0},null,null,null,null,null,null,null,null,null,null,{"$f":"H15","v":0},null,null,null,null,null,null,{"$f":"H16","v":"00:00:00"}]
[]
[null,"住    所",null,null,null,"〒",null,{"$f":"J17","v":0},null,null,null,null,{"$f":"H18","v":0}]
[null,"電話番号",null,null,null,{"$f":"H19","v":0},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 北斗受診歴"]
[null,"自宅以外の連絡先（携帯等）",null,null,null,null,null,null,null,null,null,null,{"$f":"H20","v":0},null,null,null,null,null,null,null,null,null,null,null,"□","あり",null,null,"□","なし",null,null,"□","不明"]
[null,"保険証番号",null,null,null,{"$f":"H21","v":0},null,null,null,null,null,null,null,null,"記号・番号",null,null,null,{"$f":"H22","v":0},null,null,null,null,null,null,null,null,"□","本人",null,null,"□","家族"]
[]
[]
[]
[null," 傷病名（主訴）"]
[null," 紹介目的",null,null,null,"□",null,"検 査",null,null,null,"□",null,"診 断",null,null,"□",null,"治 療",null,null,null,"□","手 術"]
[null," 患者の状況",null,null,null,"□",null,"外来でお待ちしてます",null,null,null,null,null,null,"□",null,"帰宅しています",null,null,null,null,null,"□","入院中（退院予定日   　　　          ）",null,null,null,null,null,null,null,null,null,"）"]
[null,null,null,null,null,"□",null,"歩行可能",null,null,null,null,null,null,"□",null,"車椅子を使用",null,null,null,null,null,"□","ストレッチャーが必要"]
[null," 連絡事項"]
[]
[]
[null,"◎ 必要事項をご記入頂き、診療情報提供書と一緒に上記FAX番号へ送信ください。"]
[null,"◎ 予約日時の調整がつき次第「外来予約確認票」をFAXにて送信いたしますので患者様にお渡し下さい。"]
[null,"◎ 調整に時間を要する場合はご連絡いたします。"]
[null,"◎ ご不明な点がありましたら　0155-47-3093（連携室直通）までお問い合わせください。"]
[]
[null," ※ 申込当日の受診予約はできません"]
[null," ※ 救急を要する場合、急性期での転院につきましてはDr.toDr.となっております。"]

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[null,"診療情報提供書（紹介状）"]
[]
[]
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["社会医療法人北斗"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"医療機関名",null,null,null,{"$f":"受診予約依頼票!W32","v":0}]
["北斗病院　／　北斗クリニック"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"住　所",null,null,null,{"$f":"受診予約依頼票!W34","v":0}]
[]
[null,null,null,null,null,null,null,"科",null,null,null,null,null,null,null,"医師名",null,null,null,{"$f":"受診予約依頼票!W36","v":0}]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話番号",null,null,null,{"$f":"受診予約依頼票!W38","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"FAX番号",null,null,null,{"$f":"受診予約依頼票!W40","v":0}]
[]
[]
[]
[]
[null,"ふりがな",null,null,{"$f":"受診予約依頼票!H13","v":0},null,null,null,null,null,null,null,null,null,null,null,"性 別",null,null,null,null,"　　生 年 月 日"]
[null,"患者氏名",null,null,{"$f":"受診予約依頼票!H14","v":0},null,null,null,null,null,null,null,null,null,null,null,{"$f":"受診予約依頼票!Q63","v":0},null,null,null,null,null,null,{"$f":"受診予約依頼票!X63","v":"00:00:00"}]
[]
[null,"住    所",null,null,"〒",null,{"$f":"受診予約依頼票!J17","v":0},null,null,null,{"$f":"受診予約依頼票!H18","v":0}]
[null,"電話番号",null,null,{"$f":"受診予約依頼票!H19","v":0}]
[null,"自宅以外の連絡先（携帯等）",null,null,null,null,null,null,null,null,null,{"$f":"受診予約依頼票!H20","v":0}]
[]
[]
["紹介目的"]
[]
[]
["傷病名\n（主訴又は病名）"]
[]
[]
["既往歴及び\n家族歴"]
[]
[]
[]
["病状経過及び\n検査結果\n\n治療経過"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
["現在の処方"]
[]
[]
[]
[]
[]
["その他留意事項等"]