Cover:
1, the name column should be exactly the same as the ID card.
2. Qualification level of doctor: please fill in the name of the practicing doctor (or assistant practicing doctor).
Category: Please fill in clinical or traditional Chinese medicine, public health, oral cavity.
3. Code of doctor qualification certificate: fill in the number on the doctor qualification certificate correctly, such as: 200751105101021973196564.
4. Code of doctor's practice certificate: not filled in for the time being.
5. The date, month and year in the table shall be filled in with Arabic numerals of the Gregorian calendar.
6. Time to fill in the form: fill in the time at that time.
The first page:
7. Education: The education corresponding to the application category should be filled in.
8. Professional and technical post qualifications: please fill in the doctor, attending doctor, deputy chief physician or chief physician.
If it is a teaching series, such as lecturer, associate professor and professor, please fill in the medical education network of attending physician, deputy chief physician or chief physician to search for the corresponding collection.
9. Name and registration number of the institution applying for practice: xxxx Hospital registration number: XXXX.
10. address of the institution applying for practice: XXXXXX, postcode: XXX.
1 1. Application category: clinical or traditional Chinese medicine, public health, dentistry.
12. Time for obtaining the qualification of practicing assistant physician: fill in the time listed in the Qualification Certificate of practicing assistant physician. If you are a doctor, don't fill in this item.
13. Time for obtaining the qualification of medical practitioner: fill in the time on the qualification certificate of medical practitioner. If it is a licensed assistant physician, this item is not filled in.
Page two:
14. Personal work experience: fill in the experience since joining the work.
15. Physical health status: fill in according to the results on the health check list of registered doctors, such as: good.
16. Name of business level assessment institution or organization, training time and assessment result: blank.
17. Other issues to be explained: Please fill in the scope of practice. Such as medicine or surgery.
18. Signature of the applicant: fill in the year, month and day and sign it.
Page three, page four:
19, and the filling date of each column: the same as the filling time. Grade: licensed physician and licensed assistant physician. Category: Clinical, Traditional Chinese Medicine, Public Health, Stomatology. The fourth page did not fill in the code of doctor's practice certificate.