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[null,"骨塩定量検査申込書（兼　検査終了報告書）"]
[]
[null,"申込先医療機関名",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"検査依頼元医療機関名",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,"石井整形外科"]
[null,"独立行政法人 国立病院機構　新潟病院",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,null,null,null,null,null,null,null,null,null,null,null,null,"内山整形外科医院"]
[null,"HOLOGIC社製　HorizonWi型",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"依頼元医師名",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,"恩田クリニック"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"柏崎厚生病院"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"国保北条診療所"]
[null,"患者様基本情報",null,null,null,null,null,null,null,null,null,null,null,null,null,"（新潟病院患者ＩＤ ：　　　　　　　　　　　　　　　）",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,"男","関病院"]
[null,"ﾌﾘｶﾞﾅ",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"性別",null,null,"生年　　　　月日",null,null,null,"年号",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"女","つよしクリニック"]
[null,"氏名",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,"年        月    　  日 (　   　   歳)",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"樋口内科医院扇町"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,"大正","横田整形外科医院"]
[null,"住所",null,null,"〒",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"電話",null,null,null,"  (              )      　  -",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"昭和"]
[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,null,null,null,null,null,null,null,null,null,null,null,null,null,"平成"]
[null,"検査予約日時",null,null,null,null,null,null,null,"　　　　　　　　年　　　　　　月　　　　　　日（　　　　　曜日）　　　　　　　時　　　　　　　分              ",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,null,null,null,"令和"]
[]
[null,"●希望検査項目（希望する項目にチェックをつけてください）"]
[null,null,"骨塩定量",null,null,null,null,null,null,null,null,null,"腰椎"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"腰椎＋大腿骨（右）"]
[]
[null,null,null,null,null,null,null,null,null,null,null,null,"腰椎＋大腿骨（左）"]
[]
[]
[null,"臨床診断･検査目的等（大きくはっきりと記載願います）"]
[]
[]
[]
[]
[]
[]
[]
[]
[]
[null,"整形外科的金属（人工関節等）",null,null,null,null,null,null,null,null,null,null,null,null,null,"あり",null,null,null,"なし"]
[]
[]
[null,"検査終了報告　　※新潟病院記載欄",null,null,null,null,null,"※上記にかかる検査を実施致しました。実施年月日：　　　　年　　　　月　　　　日"]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NHO新潟病院地域医療連携相談室"]
[null,"＊画像CD-Rは当院での検査後、患者様にお渡し致します。（場合によっては後日貴院宛てに郵送致します）"]