《定点门诊申请表》word版

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1、莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂

2、薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇

3、芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅

4、薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆

5、肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈

6、蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅

7、莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀

8、螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁膇蚄薃肇膃芀螅罿聿艿袈膅莇芈薇羈芃芈蚀膃腿芇螂羆肅莆袄蝿莄莅薄羄芀莄螆螇芆莃衿肃膂莂薈袅肈莂蚁肁莆莁螃袄节莀袅聿膈葿薅袂肄蒈蚇肈羀蒇衿袀荿蒆蕿膆芅蒆蚁罿膁蒅螄膄肇蒄袆羇莆蒃薆螀节薂蚈羅膈薁螀螈肄薀蒀羃肀薀蚂袆莈蕿螅肂芄薈袇袅膀薇薇肀肆蚆虿袃莅蚅螁肈芁蚅袃袁