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Fecha:______

INFORME AUDIOLGICO
Paciente: ________________________________________________________________
de ____ aos a quien se le realiz prueba de Audiomtrica en tonos puros con equipo se
MARCA SIBELMED, MODELO AC50-C, N DE SERIE 206-B613, debidamente calibrado el
30/03/2013 y Cabina Sonoamortiguadora Marca San Agustn, Modelo SISA, N de Serie
150413050, Calibrada el 26/04/2013, en la clnica Occupational Health and Safety Services
S.A.C. Encontrndose:
DIAGNOSTICO:_____________________________________________________________
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CONCLUSION FINAL:
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RECOMDEACIONES:_________________________________________________________
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FIRMA DEL ESPECIALISTA

FIRMA DEL PACIENTE

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