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FORMATO PARA REPERTORIZAR

NOMBRE DEL PACIENTE___________________________________ DOM ________________________________


FECHA________________

1________________________________________________________
6_______________________________________________________

2 _______________________________________________________ 7
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3 _______________________________________________________ 8
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4 _______________________________________________________ 9
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5 _______________________________________________________ 10
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PAG PAG
COL. COL
POSC. POSC
MED. TOT MED TOTA
AL L
LIC. HOM. ________________________________________________________