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["菊川市立総合病院　認定看護師 相談FAX用紙"]
[{"$nulls":5},"依頼日　：　　　　　　　年　　　　月　　　　日"]
[null,null,"事業所名 ："]
[null,null,"職種 ："]
[null,null,"担当者 ："]
[]
[null,"認定分野　（ 対象分野に ﾚ点 をつけて下さい ）"]
[null,"     皮膚・排泄","   緩和　","感染","　　　化学療法","  認知症","  糖尿病","　　摂食・嚥下","精神"]
[]
[null,"ご相談内容　　個別の患者様についてのご相談は＊をご記入下さい"]
[null,"　＊診察券番号：",null,"　＊患者氏名　：　",null,null,"　＊生年月日　："]
[null,"\n"]
{"$rows_empty":24}
[null,"返信方法 　（ ご希望の返信方法にﾚ点と連絡先番号をご記入下さい ）"]
[null,"TEL希望",null,"TEL番号"]
[null,"FAX希望",null,"FAX番号"]
[]
[{"$nulls":4},"【　受付　】","菊川市立総合病院地域医療支援課"]
[{"$nulls":5},"　　　TEL：0537-35-2850　　FAX：0537-35-2843"]