PREFEITURA MUNICIPAL DE CUIABÁ

SECRETARIA DE SAÚDE - SMS

SISTEMA ÚNICO DE SAÚDE - SUS

FICHA DE ENCAMINHAMENTO
Do: _________________________________________________________________ Setor: ________________________________
Para: _______________________________________________________________ Setor: ________________________________
Nome: ______________________________________________________________________________________________________
Matrícula Familiar N°: ___________________________/___________________________
Motivo: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Anotações de interesse para o caso:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Encaminhado por: _________________________________________________ Data: ________/________/________

PREFEITURA MUNICIPAL DE CUIABÁ

SECRETARIA DE SAÚDE - SMS
SISTEMA ÚNICO DE SAÚDE - SUS

FICHA DE RETORNO
Do: _________________________________________________________________ Setor: ________________________________
Para: _______________________________________________________________ Setor: ________________________________
Nome: ______________________________________________________________________________________________________
Matrícula Familiar N°: ___________________________/___________________________
Motivo: _____________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Anotações de interesse para o caso:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Encaminhado por: _________________________________________________ Data: ________/________/________