Subsemnatul (a)____________________________________, domiciliat (a) in ________________
Str. ____________________________, nr. _____, bl. _______, sc. ____, ap. ______, sector _____ Judet ___________________, posesor (posesoare) a CI seria _________, nr. _________________, eliberata la data de __________________________ de ___________________________, avand CNP ______________________________ declar pe propria raspundere ca medicul meu de familie apartine de Casa de Sanatate ________________.