Judetul _____ _______ ______ _________ Nr. fisa/carnet
de sanatate
Localitatea _____ _______ ______ _______
Unitatea sanitara ______________ 747o1422h ___ _____ _______ ______ ________
ADEVERINTA MEDICALA
Se adevereste ca: __________ ______ ____ ___________ in varsta de ____ ani,
(numele si prenumele)
cu domiciliul in: judetul _____ _______ ______ ______ localitatea _____ _______ ______ ________
str.__________ ______ ____ _____ _______ ______ _________ nr _____________
avand ocupatia de:_____ _______ ______ _____________ in _____ _______ ______ ____________
Este suferind de: __________ ______ ____ _____ _______ ______ _____________
Se recomanda __________ ______ ____ _____ _______ ______ _______________
S-a eliberat prezenta spre a-i servi la : __________ ______ ____ ___________
Semnatura si parafa medicului.
Data eliberarii:
_________ luna ___________ ziua ______ LS _____ _______ ______ __________
Judetul _____ _______ ______ _________ Nr. fisa/carnet de
sanatate
Localitatea _____ _______ ______ _______
Unitatea sanitara ______________ 747o1422h ___ _____ _______ ______ ________
ADEVERINTA MEDICALA
Se adevereste ca: __________ ______ ____ ___________ in varsta de ____ ani,
(numele si prenumele)
cu domiciliul in: judetul _____ _______ ______ ______ localitatea _____ _______ ______ ________
str.__________ ______ ____ _____ _______ ______ _________ nr _____________
avand ocupatia de:_____ _______ ______ _____________ in _____ _______ ______ ____________
Este suferind de: __________ ______ ____ _____ _______ ______ _____________
Se recomanda __________ ______ ____ _____ _______ ______ _______________
S-a eliberat prezenta spre a-i servi la : __________ ______ ____ ___________
Semnatura si parafa medicului.
Data eliberarii:
_________ luna ___________ ziua ______ LS _____ _______ ______ __________
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