JUDETUL ________________________________________________________

LOCALITATEA _____________________________________________________
UNITATEA SANITARA __________________________________________

Codul numeric personal

AVIZ EPIDEMIOLOGIC PENTRU ( RE ) INTRARE IN COLECTIVITATE

anul __________ luna ________ ziua ________

Numele ______________________ Prenumele_______________________

Prenumele tatalui ____________________
Data nasterii: anul ________ luna ______ ziua _______
Domiciliul: Loc. ______________________ str. ________________________
nr. ________ bloc _______ ap. ______ sector/ judet _________________

ARE □ / NU ARE □ semne si simptome sugestive de boala transmisibila:

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S-a eliberat prezenta pentru: _______________________________________________