外國醫(yī)師短期行醫(yī)申請表

-PAGE5-外國醫(yī)師來陜短期行醫(yī)申請表APPLICATIONFORMFORFOREIGNDOCTORSSHORT-TIMEWORKINGINSHAANXI醫(yī)師姓名SurNameGivenName性別Sex照片photo護(hù)照號(hào)PassPortID出生日期BirthDate國籍Nationality學(xué)位AcademicDegree身體狀況HealthStatus國外工作單位FormerEmployer擬在陜行醫(yī)單位PresentEmployerinShaanxi地址Address電話Telephone聯(lián)系人ContactPerson國內(nèi)推薦醫(yī)師1國內(nèi)推薦醫(yī)師2NominatedbyChinesedoctor(name)擬在陜行醫(yī)時(shí)間DurationofStayinginShaanxi行醫(yī)類型WorkDesciption1.學(xué)術(shù)交流的內(nèi)容（手術(shù)名稱）Thecontentofacademiccommunication2.短期行醫(yī)申請項(xiàng)目（請參照診療科目）ApplicationItem受委托單位醫(yī)務(wù)部審核意見Evaluationbymedicaladministrationdepartment受委托單位法人簽章Thesignatureofentrustedlegalpresentemployer

外國醫(yī)師個(gè)人簡歷RESUMEOFFOREIGNDOCTOR學(xué)歷EducationExperience何年何月Time何地何單位Place獲得何學(xué)位Academicdegree工作簡歷WorkingExperience何年何月至何年何月Time何地何單位Place從事何工作Professtion語言能力LanguageAbility母語NativeLanguage漢語水平不會(huì)聽讀說寫Chinese聘用單位配備翻譯人員姓名及語言能力、醫(yī)用技術(shù)職稱Theinterpreters’snameLanguageabilityandthetitleofmedicalprofession

外國醫(yī)師在陜行醫(yī)保證書我申請到醫(yī)院工作，在陜行醫(yī)期間，我保證遵守中國法律法規(guī)，尊重中國風(fēng)俗習(xí)慣，執(zhí)行衛(wèi)生部及陜西省衛(wèi)生行政部門的各項(xiàng)管理規(guī)定，并接受行醫(yī)所在地衛(wèi)生行政部門的監(jiān)督、檢查。外國醫(yī)師簽字年月日GUARANTEEFORFOREIGNDOCTORPRACTISEMEDICINEINSIapplyforworkinginHospital,I’llpledgetoabidebythelawsandregulationsofChina,torespectthecustomsandhabitsofChina,tocarryouttheregulationsmadebytheMinistryofPublicHealthandtheadministrationdepartmentofShaanxiMunicipalHealthBureauandtoacceptthesupervisionandinspectionbythelocaladministrationdepartment.SignatureYearMonthDate

邀請或聘用單位保證書我院聘用國家醫(yī)師來院行醫(yī)。我院保證：1、負(fù)責(zé)該醫(yī)師在院行醫(yī)期間的一切醫(yī)療責(zé)任。2、負(fù)責(zé)控制醫(yī)療質(zhì)量。3、接受衛(wèi)生行政部門監(jiān)督、檢查。法人簽字：單位公章：年月日

攜帶境外儀器、設(shè)備名稱攜帶境外藥品名