___________________________ Fuqarolik holati dalolatnomalarini yozish organi Manzil _____________________ | |
| |
____________________________________________________________________________ | |
(uy manzili) | |
____________________________________________________________________________ fuqaro_______________________________________________________________________ | |
(F.I.O., tug‘ilgan yili) | |
davolash-profilaktika muassasasiga tibbiy ko‘rikdan o‘tishga yuborilmoqda. | |
FHDY bo‘limi mudiri _________________________________ | __________ (F.I.O.) |
M.O‘. | |
Sana |
Tibbiyot muassasasi nomi, manzil___________________ _________________________ | |
m a ’ l u m o t n o m a | |
psixik (shizofreniya, epilepsiya, oligofreniya), narkologik kasalliklar, zaxm, sil va OIV/OITS yuzasidan | |
_____________________________________________________________________________ | |
(uy manzili) | |
______________________________________________________________________________ | |
(F.I.O., tug‘ilgan yili) | |
Nikohlanuvchi shaxslarni tibbiy ko‘rikdan o‘tkazish to‘g‘risidagi Nizomga muvofiq tekshirildi. | |
Davolash-profilaktika muassasasi xulosasi: | |
_____________________________________________________________________________ | |
Bosh vrach | ________________________________ |
M.O‘. | |
Sana |