ALUMNO: ____________________________

DOCENTE: ____________________________
N° FOLIO: ____________________________
FECHA: ____________________________

FICHA CIRUGIA CLINICA

Facultad de Odontología

DATOS ESTADISTICOS

NOMBRE

RUT F. DE NACIMIENTO
EDAD SEXO
ESTADO CIVIL OCUPACIÓN
TELÉFONO TELÉFONO DE
EMERGENCIA

MOTIVO DE CONSULTA _____________________________________________________________

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EVOLUCIÓN/SINTOMAS DE LA ENFERMEDAD ACTUAL ____________________________________

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FECHA EVOLUCIÓN FIRMA