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:
________________________________________________________________________ ________________________________________________________________________ S-a eliberat prezenta pentru: _______________________________________________