Receta Extra FR000
Receta Extra FR000
Receta Extra FR000
R.N.O.S. Nº 1-1190-2
Av. Belgrano 665 (1092) - C.A.B.A. 4340-7400
DNI:__________________________________________________________________________
INSTITUCIÓN:_______________________________________________________________
LUGAR:______________________________________________________________________
DIAGNÓSTICO:_______________________________________________________
MÉDICO PRESCRIPTOR:_______________________________________________
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LUGAR:______________________________________________________________________
FARMACIA:_________________________________________________________________
FIRMA MÉDICO ESPECIALISTA
FECHA DE DISPENSA:________________________________________________________
AUDITORÍA MÉDICA:
FECHA DE CONTROL:________________________________________
FIRMA Y SELLO AUDITOR