ALUMNO: ____________________________
DOCENTE: ____________________________
N° FOLIO: ____________________________
FECHA: ____________________________
FICHA CIRUGIA CLINICA
Facultad de Odontología
DATOS ESTADISTICOS
NOMBRE
RUT F. DE NACIMIENTO
EDAD SEXO
ESTADO CIVIL OCUPACIÓN
TELÉFONO TELÉFONO DE
EMERGENCIA
MOTIVO DE CONSULTA _____________________________________________________________
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EVOLUCIÓN/SINTOMAS DE LA ENFERMEDAD ACTUAL ____________________________________
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FECHA EVOLUCIÓN FIRMA
