FORMATO PARA REPERTORIZAR

NOMBRE DEL PACIENTE___________________________________ DOM ________________________________ FECHA________________

1________________________________________________________ 6_______________________________________________________

2 _______________________________________________________ 7 _______________________________________________________

3 _______________________________________________________ 8 _______________________________________________________

4 _______________________________________________________ 9 _______________________________________________________

5 _______________________________________________________ 10 _______________________________________________________

PAG PAG
COL. COL
POSC. POSC
MED. TOTAL MED TOTAL

LIC. HOM. ________________________________________________________