16 yoshgacha bo‘lgan nogiron bolaga beriladigan
TIBBIY XULOSA-KOREShOGI
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____-son
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20___ y. “__” __________
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___________ tuman (shahar)
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1. Bolaning familiyasi, ismi, otasining ismi_______________________________
_______________________________________________________________________.
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2.Tug‘ilgan yili (oyi, sanasi) _____________________________________________
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3. Bolaning ota-onasi yoki ularning o‘rini bosuvchi shaxslarning familiyasi, ismi, otasining ismi (keraklisini chizing) _________________________________
_______________________________________________________________________.
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4. Ota-onasining yoki ularning o‘rnini bosuvchi shaxslarning doimiy yashash joyi
_______________________________________________________________________
_______________________________________________________________________.
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5. Kasallik (patologik holat) _____________________________________________
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___________________ taalluqli bo‘lim ________________ bandga_______________
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band bo‘limiga _______________________ tegishliligi _______________________
_______________________________________________________________________
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Tibbiy ko‘rsatmalar ro‘yxati
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20___ y. “___” ________ gacha haqiqiy
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Bolaning protez-ortopediya mahsulotlari va reabilitatsiya texnik vositalarga muhtojligi:
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Ha (nomi) ______________________________________________________________
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Yo‘q.
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Qayta ko‘rikdan o‘tish sanasi 20___ y. “___” ______________
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TMK raisi
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___________________________________
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(F.I.Sh., imzosi)
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TMK a’zolari
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___________________________________
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(F.I.Sh., imzosi)
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20 ___ y. “___” __________ tuman (shahar) ijtimoiy ta’minot bo‘limiga yuborildi
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Manzili: _______________________________________________________________
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Aloqa bo‘limining kvitansiyasi № _________________ dan
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