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[]
[]
["済生会呉病院",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,null,null,null,null,null,null,null,null,null,{"$f":"TODAY()","v":"2023-08-08"}]
[null," 地域医療連携室　宛",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"紹介元医療機関"]
[]
[null,null,"ＴＥＬ ０８２３ー２１－１６１６(直通)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 所在地"]
[]
[null,null,"ＦＡＸ ０８２３ー２０－０５８０(直通)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 名　称"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 医師名"]
["患者情報"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," ＴＥＬ"]
[]
["診察券番号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," ＦＡＸ"]
[]
[]
[]
["フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"    男",null,null,"保険者番号"]
["氏　　名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"・"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"    女",null,null,"記号・番号"]
["生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",{"$f":"IF(G21>1910,DATEDIF(G21,TODAY(),\"Y\"),\"\")","v":""},null,null,"歳",null,")","公費番号"]
["現 住 所",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,null,null,null,null,null,null,null,null,null,null,"受給者番号"]
["電話番号",null,null,null,null,null,null,null,null,null,null,"－",null,null,null,null,null,null,"－"]
[]
["診　療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検　査"]
[null,null,null,"　内科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　ＭＲＩ",null,null,null,null,"　造影・　単純",null,null,null,null,null,null,null,"(部位：",null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,"　心療内科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　ＣＴ",null,null,null,null,"　造影・　単純",null,null,null,null,null,null,null,"(部位：",null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,"　外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　大腸内視鏡検査"]
[null,null,null,"　整形外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　胃内視鏡検査",null,null,null,null,null,null,null,null,"　経口・　経鼻"]
[null,null,null,"　眼科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　その他の検査",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,"　耳鼻咽喉科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　栄養指導"]
["  ＊入院の希望",null,null,null,null,null,null,null,null,"    有",null,null,"･","    無",null,null,null,null,null,"　＊検査結果のＦＡＸ希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 有",null,null,null,null,null,"･","無"]
["※緊急の場合は、直接各科の医師へ\n電話依頼をお願いします。"]
["紹介目的\n病状等",null,null,null,null,null,"　　　　",null,null,"　診療",null,null,null,null,null,null,null,null,null,null,"　　　　",null,null,"　診療 ＋ 検査",null,null,null,null,null,null,null,null,null,null,null,"　　　　",null,null,"　検査のみ"]
[]
[]
[]
["希望医師",null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,")","医師",null,null,"／",null,"連絡",null,null,"    済",null,null,"･","    未",null,null,"指定なし"]
[]
["診療検査\n希望日",null,null,null,null,null,"第１希望",null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,")","　午前",null,null,null,"･","　午後",null,null,null,null,"　最短日を希望"]
[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,null,null,null,null,null,null,null,null,"　ご都合の悪い日"]
[null,null,null,null,null,null,"第２希望",null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,")","　午前",null,null,null,"･","　午後"]
[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,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,")","以外希望"]
["患者さんは",null,null,null,null,null,null,null,null," お返事待ちで在院中",null,null,null,null,null,null,null,null,null,null,null,null,null," 帰宅されています",null,null,null,null,null,null,null,null,null,null,null,null,null,null," 入院中"]
["移動方法",null,null,null,null,null,"　独歩・　介助歩行・　車椅子・　ストレッチャー",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,null,"認知症",null,null,null,null,null,null,"　 有",null,null,"･","　無"]
["来院方法",null,null,null,null,null,"　介護タクシー・　施設の車・　救急車・　他(",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,")","同伴者",null,null,null,null,null,null,"　 有",null,null,"･","　無"]
[]
["決定日時",null,null,null,null,null,"　　月　　　日（　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"来院　　：　　　",null,null,null,null,null,null,null,null,null,"検査　　：　　　"]

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[]
[]
[]
[null,"済生会呉病院",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,null,null,null,null,null,null,null,null,null,{"$f":"TODAY()","v":"2023-08-08"}]
[null,null," 地域医療連携室　宛",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,"紹介元医療機関"]
[]
[null,null,null,"ＴＥＬ ０８２３ー２１－１６１６(直通)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 所在地"]
[]
[null,null,null,"ＦＡＸ ０８２３ー２０－０５８０(直通)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," 名　称"]
[]
[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,null," 医師名"]
[null,"患者情報"]
[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,null," ＴＥＬ"]
[]
[null,"診察券番号",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," ＦＡＸ"]
[]
[]
[]
[null,"フリガナ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"    男",null,null,"保険者番号"]
[null,"氏　　名",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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"    女",null,null,"記号・番号"]
[null,"生年月日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"(",null,null,null,"歳",null,")","公費番号"]
[null,"現 住 所",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,null,null,null,null,null,null,null,null,null,null,null,"受給者番号"]
[null,"電話番号",null,null,null,null,null,null,null,null,null,null,"－",null,null,null,null,null,null,"－"]
[]
[null,"診　療",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検　査"]
[null,null,null,null,"　内科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　ＭＲＩ",null,null,null,null,"　造影・　単純",null,null,null,null,null,null,null,"(部位：",null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,"　心療内科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　ＣＴ",null,null,null,null,"　造影・　単純",null,null,null,null,null,null,null,"(部位：",null,null,null,null,null,null,null,null,null,null,null,null,")"]
[null,null,null,null,"　外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　大腸内視鏡検査"]
[null,null,null,null,"　整形外科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　胃内視鏡検査",null,null,null,null,null,null,null,null,"　経口・　経鼻"]
[null,null,null,null,"　眼科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　その他の検査",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,null,"　耳鼻咽喉科",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　栄養指導"]
[null,"  ＊入院の希望",null,null,null,null,null,null,null,null,"    有",null,null,"･","    無",null,null,null,null,null,"　＊検査結果のＦＡＸ希望",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"　 有",null,null,null,null,null,"･","無"]
[null,"※緊急の場合は、直接各科の\n医師へ電話依頼をお願いします。"]
[null,"紹介目的\n病状等",null,null,null,null,null,"　　　　",null,null,"　診療",null,null,null,null,null,null,null,null,null,null,"　　　　",null,null,"　診療 ＋ 検査",null,null,null,null,null,null,null,null,null,null,null,"　　　　",null,null,"　検査のみ"]
[]
[]
[]
[null,"希望医師",null,null,null,null,null,"(",null,null,null,null,null,null,null,null,null,null,null,null,")","医師",null,null,"／",null,"連絡",null,null,"    済",null,null,"･","    未",null,null,"指定なし"]
[]
[null,"診療検査\n希望日",null,null,null,null,null,"第１希望",null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,")","　午前",null,null,null,"･","　午後",null,null,null,null,"　最短日を希望"]
[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,null,null,null,null,null,null,null,null,null,"　ご都合の悪い日"]
[null,null,null,null,null,null,null,"第２希望",null,null,null,null,null,null,null,"月",null,null,null,null,"日",null,"(",null,null,")","　午前",null,null,null,"･","　午後"]
[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,null,null,null,null,null,null,null,null,null,"(",null,null,null,null,null,null,null,null,")","以外希望"]
[null,"患者さんは",null,null,null,null,null,null,null,null," お返事待ちで在院中",null,null,null,null,null,null,null,null,null,null,null,null,null," 帰宅されています",null,null,null,null,null,null,null,null,null,null,null,null,null,null," 入院中"]
[null,"移動方法",null,null,null,null,null,"　独歩・　介助歩行・　車椅子・　ストレッチャー",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,null,"認知症",null,null,null,null,null,null,"　 有",null,null,"･","　無"]
[null,"来院方法",null,null,null,null,null,"　介護タクシー・　施設の車・　救急車・　他(",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,")","同伴者",null,null,null,null,null,null,"　 有",null,null,"･","　無"]
[]
[null,"決定日時",null,null,null,null,null,"　　月　　　日（　　　）",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"来院　　：　　　",null,null,null,null,null,null,null,null,null,"検査　　：　　　"]

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["〇",null,"月"]
["　　　　",null,"火"]
[null,null,"水"]
[null,null,"木"]
[null,null,"金"]