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[]
[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:　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,"総合診療科",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,"泌尿器科",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,"皮膚科",null,null,null,null,"□",null,"甲状腺外来",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,"小児科",null,null,null,null,"□",null,"放射線治療科",null,null,null,null,null,"□",null,"セカンドオピニオン"]
[null,"□","リンパ浮腫外来",null,null,null,null,null,"□",null,"心血管・不整脈センター （循環器内科・心臓血管外科）"]
[null,"□","その他（　　　　　　　　　　）"]
[]
[]
["【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,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,"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、改めてご連絡いたします。"]
[null,"◎ ご不明な点がありましたら　TEL: 0155-47-3093（連携室直通）までお問い合わせください。"]
[]
[null," ※ 予約依頼当日に受診希望の際は、予約なしで診療時間にお越し頂いております。(予約は翌日以降となります。)"]
[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. 当院担当医師へ電話をおつなぎ致します。"]