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[]
[null,null,null,null,null,"核医学検査（SPECT/CT検査）における同意書"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"カナ："]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ID:",null,null,null,null,null,null,null,null,null,null,"氏名："]
[]
[null,null,"独立行政法人　　　　　　国立病院機構",null,null,null,null,null,"新潟病院　病院長　殿"]
[]
[]
[null,null,null,"私は、核医学検査（SPECT/CT検査）の内容・注意事項について説明を受け、質問する機会"]
[null,null,"を得ました。"]
[null,null,"その結果、核医学検査（SPECT/CT検査）を受けることに同意します。"]
[]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"年　　月　　日"]
[]
[]
[]
[null,null,null,null,"患者氏名"]
[]
[]
[null,null,null,null,"保護者または代理人氏名（患者様が未成年または記入できない場合）"]
[]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"（続柄）"]
[]
[]
[]
[]
[]
[null,null,null,null,"診療科名"]
[]
[]
[null,null,null,null,"説明医師氏名"]
[]
[]
["独立行政法人　国立病院機構　新潟病院"]