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["用紙-B44-8(13-04-01)"]
["用紙-721-01 (13-04-01)"]
["検査依頼書"]
["　　年　　月　　日"]
["一般社団法人　",null,null,null,"≪依頼者≫","住所　〒(　　　−　　　　)"]
["長野県薬剤師会 会長 様",null,null,null,"（結果書掲載名)"]
["次の内容の検査を依頼します。",{"$nulls":4},"氏名：　　　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":5},"TEL：　　　　　　　　　　　　　　　　　　　　　 "]
["受付番号：",null,null,null,"≪結果書送付先≫","住所　〒(　　　−　　　　)"]
[{"$nulls":5},"　　　　　　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":5},"氏名：　　　　　　　　　　　　　　　　　　　　　"]
[{"$nulls":5},"TEL：　　　　　　　　　　　　　　　　　　　　　 "]
[{"$nulls":4},"≪請求書≫","宛名：　　　　　　　　　　　　　　　　　　　　  "]
[]
["依頼区分"]
[null,"薬事関連検査"]
[]
["試料種別・試料名",null,"医薬品・医薬部外品・化粧品・医療機器・その他"]
[null,null,"（具体的な製品名、ロットなどをお書きください）"]
[]
[]
[]
[]
["検　査　項　目"]
[]
[]
[]
[]
[]
[]
["備　考　欄",null,null,"（その他必要事項ありましたらをお書きください）"]
[]
[]
[]
[]
[]
["検査料",null,"未請求・請求済・領収済",null,"請求額",null,null,"受付担当者","入力確認"]
[]
["結果書発行日"]
["請求書発行番号"]
["※お問合せ先：長野県薬剤師会検査センター　"]
["              〒390-0802　長野県松本市旭2-11-20  TEL：0263-32-0276、FAX：0263-36-0665"]