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Patto territoriale - ASL Lecco

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OSPEDALE DI LECCO<br />

AZIENDA OSPEDALIERA<br />

PROVINCIALE DEL S.S.N.<br />

RELAZIONE CLINICA AL MEDICO CURANTE<br />

MOD. DL 17.4a<br />

REV.000<br />

Al / Alla Dott._________________________________________________________________________________<br />

Il/la Sig./Sig.ra _______________________________________________________________________________<br />

Visitato/a presso il nostro C.P.S. in data_________________________________________________________<br />

con diagnosi ___________________________________________________________________________________<br />

_______________________________________________________________________________________________<br />

_______________________________________________________________________________________________<br />

Viene affidato/a al Curante Presa in cura per un periodo di mesi……….<br />

E’ previsto un approfondimento diagnostico Invio presso altra Agenzia<br />

Progetto terapeutico Integrato /Consiglio Terapeutico_______________________________________________<br />

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Controllo previsto per il giorno:___________________________________<br />

Richiederei la Sua collaborazione per:<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

________________________________________________________________________________________________<br />

Sono a Sua disposizione per un contatto telefonico il dalle alle<br />

Data______________________<br />

Timbro e Firma<br />

Centro Psicosociale di <strong>Lecco</strong>- Sede operativa di Bellano, Via C. Alberto,25 – 23822 Bellano - 0341 829325

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