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{"sheet":"D.頭部X線規格撮影（セファロ）予約申込書 ","index":0,"n_rows":49,"n_cols":16,"rows_kept":49,"cut":false,"hidden":false,"merged":[[34,14,34,15],[35,14,36,15],[34,2,34,6],[35,2,36,6],[35,13,36,13],[43,1,43,2],[44,1,44,2],[46,0,46,10],[46,11,46,15],[37,1,37,5],[38,0,39,15],[40,10,40,15],[34,0,34,1],[35,0,36,1],[16,3,16,4],[16,6,16,7],[16,9,16,10],[17,3,17,4],[17,6,17,7],[17,9,17,10],[35,7,36,12],[34,7,34,12],[15,3,15,4],[15,6,15,7],[15,9,15,10],[0,0,2,15],[3,9,3,10],[5,0,5,2],[5,8,5,9],[10,1,10,4],[7,10,7,15],[9,10,9,15],[11,9,11,15],[12,9,12,15]]}
["Ｄ 頭部Ｘ線規格撮影（セファロ）予約申込書〈ＦＡＸ専用〉"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,"年",null,"月",null,"日"]
[]
["紹介診療科",null,null,null,null,null,null,null,"紹介元"]
[]
["総合大雄会病院　口腔外科",null,null,null,null,null,null,null,"所在地"]
[]
[null,null,null,null,null,null,null,null,"医療機関名"]
[null,null,null,null,null,"医師"]
[null,null,null,null,null,null,null,null,"TEL"]
["ＴＥＬ　０５８６－７２－１２１１（内線２１１２）",null,null,null,null,null,null,null,"FAX"]
[]
["★撮影希望日"]
[null,"第１希望",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[null,"第２希望",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[null,"第３希望",null,null,null,"年",null,null,"月",null,null,"日","(",null,")"]
[]
["★撮影方法",null,"（数字をダブルクリックすると〇印がつきます）"]
[]
[null,1,"正面（１方向）",null,null,null,2,"側面（１方向）",null,null,null,3,"正側両方向（２方向）"]
[]
["★確認事項（希望の数字上をダブルクリックすると〇印がつきます）"]
[null,"撮影後フィルムは"]
[null,1,"撮影当日患者さまにお渡しする",null,null,null,null,null,2,"当院より貴院へ郵送する"]
[]
["★撮影料金"]
[null,"正面（１方向）",null,null,null,null,"１１，０００円（税込）"]
[null,"側面（１方向）",null,null,null,null,"１１，０００円（税込）"]
[null,"正側両方向（２方向）",null,null,null,null,"１２，１００円（税込）"]
[]
["★患者さま氏名"]
[null,"(保険証の写しまたは診療録の表紙の写しでも結構です。）"]
["フリガナ",null,null,null,null,null,null,"生年月日",null,null,null,null,null,"年齢","性別"]
["患者氏名"]
[]
["〒"]
[]
[]
[null,null,null,null,null,null,null,null,null,"TEL"]
[]
["★受付時間　（祝日・年末年始（12月31日～1月3日）を除く）"]
[null,"月～金",null,null,"８：３０～１９：００"]
[null,"土",null,null,"８：３０～１２：３０"]
[null,"（ＦＡＸは24時間稼働。但し、受付時間外・休日着信分は翌日以降対応）"]
["送付先　　総合大雄会病院　地域医療連携室　　　\n                                                         　 　",null,null,null,null,null,null,null,null,null,null,"FAX 0586-24-9999"]
["※右記のFAX番号を確認後送信してください。"]
["※個人情報の取扱いについては慎重にお願いします。"]