INSTÃLLD OPERATION - Södersjukhuset
INSTÃLLD OPERATION - Södersjukhuset
INSTÃLLD OPERATION - Södersjukhuset
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Verksamhetsområde Specialistvård<br />
Urologiska kliniken<br />
Ansökan<br />
Ansökan om ekonomisk kompensation med anledning av<br />
inställd operation<br />
Namn:_________________________<br />
Adress:________________________<br />
Personnummer: ____________________<br />
Telefonnummer:____________________<br />
______________________________<br />
Datum och tidpunkt för planerad operation:__________________________________<br />
Klinik/avdelning:_______________________________________________________<br />
Bank:__________________________<br />
Bankkontonummer (även clearingnummer):__________________________________<br />
Övrigt (ev beskrivning)<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_____________________________________________________________________<br />
_______________________________________<br />
Datum och underskrift
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