Гинеколог/Уролог (для мужчин обязательно)

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Диагноз: __________________________________________________________________

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Заключение: _______________________________________________________________

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"__" ________________ 20__ г. _____________ ___________________

(месяц прописью) (подпись) (расшифровка)

Диагнозы (по-русски) и заключение ВВК о причинной связи заболевания, увечья

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