GHSIF - Site de Melun Sénart - Service Cardiologie - Demande d'avis différé

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Je certifie que le (la) patient(e) consent à l'envoi de ses données personnelles dans le cadre de cette demande d'avis auprès du Service Cardiologie du Groupe Hospitalier Sud Île-de-France

Consentement du patient

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GHSIF - Site de Melun Sénart - Service Cardiologie - Demande d'avis différé

Informations importantes

Identité du patient

Sexe du patient

Coordonnées du patient

Date de réponse souhaitée

Rédaction de la demande

Détaillez ci-dessous l'objet de la demande et les détails que vous jugez importants afin de recevoir un avis éclairé de la part du médecin (contexte clinique, antécédent, etc.)

Optionnel - Ajoutez ci-dessous une ou des photos afin de préciser la demande

Optionnel - Ajoutez ci-dessous un ou des fichiers afin de préciser la demande

Recueil du consentement

Consentement du patient