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["　芳賀赤十字病院　薬剤部"]
["　FAX：0285-83-3876",null,null,"服薬情報提供書",null,null,null,null,"記入年月日：",null,{"$f":"TODAY()","v":"2024-04-15"}]
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["　　　ＩＤ：",null,null,null,null,null,"　保険薬局　店舗名／住所／ＴＥＬ／ＦＡＸ"]
["　患者名：",null,null,null,null,null,"　"]
["　報告について患者からの同意："]
[null,null,null,null,null,null,"　担当薬剤師名："]
["　　処方科："]
["　処方医師名：",null,null,null,null,null,"処方箋交付年月日："]
["　報告内容："]
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["　詳細：　特に残薬調整や服薬状況等の報告については、その理由などの記入をお願いします。"]
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["返信について","□返信不要　（全てに該当チェックがなければ、返信不要と判断します。）"]
[null,"□受領報告を希望する。"]
[null,"□返信を希望する。"]
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["　医師/薬剤部からの返信欄"]
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[null,null,null,null,null,null,"芳賀赤十字病院　薬剤部　　FAX：0285-83-3876"]