RED DE SALUD H. A. Y.

YUNGUYO

HOJA DE INTERCONSULTA
PACIENTE: …………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

EDAD: ………………………………………….. SEXO: F M FECHA: / /

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ESPECIALIDAD:
MOTIVO DE INTERCONSULTA:
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DIAGNOSTICO:
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MEDICO EVALUADOR:

NOMBRE COMPLETO:
CMP: _________________________________________

FIRMA Y SELLO:
RESPUESTA DE LA INTERCONSULTA

EVALUACIÓN:
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DIAGNOSTICO: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

INDICACIONES MEDICAS Y CONCLUSION: ………………………………………………………………………………………………………………………………………………………………………………….

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MEDICO EVALUADOR:
NOMBRE COMPLETO:
CMP: RNE:
 RED DE SALUD H. A. Y.
YUNGUYO

FIRMA Y SELLO: ………………………………………………………………………………………

FECHA Y HORA: