| Signature | Name | Date | Time | |
|---|---|---|---|---|
| Patient | ||||
| Witness (relation with patient) | ||||
| Doctor | ||||
| Interpreter |
Official websites use .gov
A
.gov website belongs to an official
government organization in the United States.
Secure .gov websites use HTTPS
A lock (
) or https:// means you've safely
connected to the .gov website. Share sensitive
information only on official, secure websites.