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DECLARATIE

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 ________________.

Data:

Semnatura

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