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Facultatea de Medicina Dentara Medic………………………..Str. Ilarie Voronca nr. 7, Constanta Student………………………Tel/fax: 02!"##$%7 Data………………………….

FISA DE TRATAMENT DENTAR NR. ………….

&'M(………………………)*(&'M(……………………….anul nasterii…………Do+iciliu localitatea-………………………..ud……Str……………………………..

&r……..loc……….(ta………1……..Tel…………………………………………...

 13C………………………………………………………………………………………..

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 1ntecedente ersonale………………………………………………………………….

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(x. 4ncolo5ic re6enti6..………………………………………………………………..

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. .7 .$ .# . .8 .2 .! 8.! 8.2 8.8 8. 8.# 8.$ 8.7 8.

D5. 9eneral............................................................................................................

D5. Sto+atolo5ic....................................................................................................

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)lan de trata+ent...................................................................................................

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Facultatea de Medicina Dentara Medic………………………..Str. Ilarie Voronca nr. 7, Constanta Student………………………Tel/fax: 02!"##$%7 Data………………………….

FISA DE TRATAMENT DENTAR NR. ………….

&'M(………………………)*(&'M(……………………….anul nasterii…………Do+iciliu localitatea-………………………..ud……Str……………………………..

&r……..loc……….(ta………1……..Tel…………………………………………...

 13C………………………………………………………………………………………..

……………………………………………………………………………………………..

 1ntecedente ersonale………………………………………………………………….

……………………………………………………………………………………………..

(x. 4ncolo5ic re6enti6..………………………………………………………………..

!. !.7 !.$ !.# !. !.8 !.2 !.! 2.! 2.2 2.8 2. 2.# 2.$ 2.7 2.

  #.# #. #.8 #.2 #.! $.! $.2 $.8 $. $.#

.# . .8 .2 .! 7.! 7.2 7.8 7. 7.#

. .7 .$ .# . .8 .2 .! 8.! 8.2 8.8 8. 8.# 8.$ 8.7 8.

D5. 9eneral............................................................................................................

D5. Sto+atolo5ic....................................................................................................

...............................................................................................................................

...............................................................................................................................

)lan de trata+ent...................................................................................................

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CNP

CNP

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Data Diagnostic Tratament efectuat Semn./parafa Data Diagnostic Tratament efectuat Semn./parafa