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AD.FR.015 - HASTA EŞYASI TESLİM FORMU

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Demo Hastanesi (Prokalite.Com) HASTA EŞYASI TESLİM FORMU

Doküman Kodu: AD.FR.015

Yayın Tarihi: 08.12.2016

Revizyon Tarihi: 02.11.2021

Revizyon No: 1

Sayfa: Otomatik

Adı-Soyadı:					Telefon:

Adres:
Alınan Eşyanın
Sıra	Cinsi			Renk		Miktarı	Açıklama
1

2

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Yukarıda cinsi, miktarı ve birimi belirtilen malzemeler…………………………………………………….....tarafından
………………………………isimli (Hastane Polisi/Sağlık Personeli/Hastane Nöbetçi Memuruna/Hasta yakınına) teslim edilmiştir.


Tarih: …./…./…. Saat:
Teslim Eden		Teslim Eden	Teslim Alan		Teslim Alan

<meta charset="utf-8"/>
<table style="border-collapse: collapse; width: 882px;" class=" cke_show_border" cellspacing="0"><tbody><tr><td colspan="5" style="border-bottom:1px solid black; border-left:3px double black; border-right:1px solid black; border-top:3px double black; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Adı-Soyadı:</span></strong></span></td><td colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:3px double black; border-top:3px double black; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Telefon:</span></strong></span></td></tr><tr><td colspan="8" style="border-bottom:none; border-left:3px double black; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:none; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Adres:</span></strong></span></td></tr><tr><td colspan="8" style="background-color:#c6c8ca; border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:1px solid black; text-align:left; vertical-align:middle"><span style="font-size:13px"><span style="color:black"><strong>Alınan Eşyanın</strong></span></span></td></tr><tr><td style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">Sıra</span></strong></span></td><td colspan="3" style="border-color: black black black currentcolor; border-style: solid solid solid none; border-width: 1px 1px 1px medium; text-align: center; vertical-align: middle; width: 512px;"><span style="font-size:13px"><strong><span style="color:black">Cinsi</span></strong></span></td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Renk</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Miktarı</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:3px double black; border-top:none; text-align:left; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Açıklama</span></strong></span></td></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">1</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">2</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">3</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">4</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">5</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">6</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">7</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">8</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">9</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">10</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">11</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">12</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">13</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">14</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td rowspan="2" style="border-color: currentcolor black black; border-style: none solid solid double; border-width: medium 1px 1px 3px; text-align: center; vertical-align: middle; width: 186px;"><span style="font-size:13px"><strong><span style="color:black">15</span></strong></span></td><td colspan="3" rowspan="2" style="border-color: black; border-style: solid; border-width: 1px; vertical-align: middle; width: 512px;"><br></td><td colspan="2" rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td rowspan="2" style="border-bottom:1px solid black; border-left:1px solid black; border-right:3px double black; border-top:none; vertical-align:middle"><br></td></tr><tr></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr><tr><td colspan="8" style="border-bottom:none; border-left:3px double black; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr><tr><td colspan="8" style="border-bottom:none; border-left:3px double black; border-right:3px double black; border-top:none; text-align:left; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Yukarıda cinsi, miktarı ve birimi belirtilen malzemeler…………………………………………………….....tarafından</span></strong></span></td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:none; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">………………………………isimli (Hastane Polisi/Sağlık Personeli/Hastane Nöbetçi Memuruna/Hasta yakınına) teslim edilmiştir.</span></strong></span></td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr><tr><td colspan="8" style="border-bottom:1px solid black; border-left:3px double black; border-right:3px double black; border-top:1px solid black; text-align:left; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Tarih: …./…./…. Saat:</span></strong></span></td></tr><tr><td colspan="2" style="border-bottom:1px solid black; border-left:3px double black; border-right:1px solid black; border-top:1px solid black; text-align:left; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Teslim Eden</span></strong></span></td><td style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:none; text-align:left; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Teslim Eden</span></strong></span></td><td colspan="2" style="border-bottom:1px solid black; border-left:none; border-right:1px solid black; border-top:1px solid black; text-align:center; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Teslim Alan</span></strong></span></td><td colspan="3" style="border-bottom:1px solid black; border-left:none; border-right:3px double black; border-top:1px solid black; text-align:center; vertical-align:middle"><span style="font-size:13px"><strong><span style="color:black">Teslim Alan</span></strong></span></td></tr><tr><td colspan="2" style="border-bottom:3px double black; border-left:3px double black; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td style="border-bottom:3px double black; border-left:none; border-right:1px solid black; border-top:none; vertical-align:middle"><br></td><td colspan="2" style="border-bottom:3px double black; border-left:none; border-right:1px solid black; border-top:1px solid black; vertical-align:middle"><br></td><td colspan="3" style="border-bottom:3px double black; border-left:none; border-right:3px double black; border-top:1px solid black; vertical-align:middle"><br></td></tr></tbody></table>