{"text_format":"1","workbook":"xlsx","n_sheets":1,"sheets":["受診予約依頼票"],"not_rendered":{"charts":0,"images":0,"macros":1,"external_links":0,"defined_names":2,"comments":0,"pivot_tables":0},"unopened":[],"bounds":{"document_bytes":16777216,"sheet_cells":100000,"rows_first":2000,"rows_last":500,"rows_between":2000,"halvings":0,"cell_chars":16384,"cell_head_chars":4096},"cells_cut":0,"cells_raw":0,"read":"whole","date_system":"1900"}

{"sheet":"受診予約依頼票","index":0,"n_rows":60,"n_cols":35,"rows_kept":60,"cut":false,"hidden":false,"merged":[[1,1,1,34],[5,0,7,12],[7,17,8,21],[7,22,8,34],[8,0,9,12],[9,17,10,21],[9,22,10,34],[10,0,11,13],[4,26,4,27],[4,29,4,30],[4,32,4,33],[4,24,4,25],[22,8,22,9],[22,15,22,16],[22,23,22,24],[11,17,12,21],[11,22,12,34],[12,0,13,13],[13,17,14,21],[13,22,14,34],[14,0,15,13],[15,17,16,21],[15,22,16,34],[17,17,18,21],[17,22,18,34],[21,8,21,9],[21,15,21,16],[21,23,21,24],[25,21,25,29],[23,8,23,9],[23,15,23,16],[23,23,23,24],[24,8,24,9],[24,15,24,16],[24,23,24,24],[30,18,30,19],[30,22,30,25],[30,26,30,27],[30,29,30,30],[31,3,31,9],[25,8,25,9],[25,15,25,16],[30,1,30,3],[30,4,30,5],[30,7,30,8],[30,11,30,14],[30,15,30,16],[37,31,38,31],[37,32,38,33],[37,34,38,34],[38,17,38,18],[36,1,36,4],[36,5,36,15],[36,21,36,34],[50,1,50,4],[50,5,50,34],[48,5,48,6],[49,5,49,6],[40,1,40,4],[40,5,40,22],[40,23,40,34],[41,25,41,27],[41,29,41,31],[41,33,41,35],[41,1,41,11],[41,12,41,22],[42,14,42,17],[47,5,47,6],[48,1,49,4],[48,14,48,15],[47,18,47,20],[47,23,47,25],[49,14,49,15],[48,29,48,32],[42,18,42,26],[42,28,42,30],[42,32,42,34],[47,1,47,4],[47,7,47,9],[47,11,47,12],[47,13,47,14],[47,16,47,17],[42,1,42,4],[42,5,42,13],[46,1,46,4],[46,5,46,34],[31,11,31,12],[31,22,31,30],[39,1,39,4],[39,5,39,6],[39,7,39,12],[39,13,39,34],[37,1,38,4],[37,5,38,15],[37,17,37,18],[37,26,38,27],[37,28,38,28],[37,29,38,30]]}
[]
[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,"令和",null,null,null,"年",null,null,"月",null,null,"日"]
["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"]
["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"]
["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"]
["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"]
["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,null,null,null,null,null,null,null,null,null,null,null,null,null,"担当者名"]
[]
["【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,"）"]
[]
["【患者情報欄】"]
[]
[]
[null,"ふりがな",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"生 年 月 日"]
[null,"患者氏名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□","男",null,null,null,"□","大正","□","昭和",null,null,null,"年",null,null,"月",null,null,"日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"□","女",null,null,null,"□","平成","□","令和"]
[null,"住    所",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," 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,null,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,null,null,null,null,null,null,null,null,null,"記号・番号",null,null,null,null,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。"]