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Get DA 3647 1979-2024

BED DAYS f. TOTAL SICK DAYS 36. Total Days All Facilites SIGNATURE OF ATTENDING MEDICAL OFFICER DA FORM 3647 MAY 1979 SIGNATURE OF PAD OR MEDICAL RECORDS OFFICER EDITION OF 1 AUG 76 IS OBSOLETE APD LC v1. INPATIENT TREATMENT RECORD COVER SHEET For use of this form see AR 40-400 the proponent agency is OTSG REGISTER NUMBER SEX FMP FLYING STATUS SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 27a* ADDRESS OF EMERGENCY ADDRESSEE Include ZIP Code 27b. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY SELECTED ADMINISTRATIVE DATA AGE RACE SSN NAME Last First MI RELIGION RATING/ DSG DEPT. / BEN LENGTH OF SVC ORGANIZATION BRANCH/CORPS ETS UIC/ZIP HOURS OF ADMISSION GRADE PREVIOUS WARD TYPE CASE CLINIC SERVICE TYPE DISPOSITION DATE OF DISPOSITION TELEPHONE NO. DATE OF THIS DATE OF INTIAL ADMISSION REMARKS ADMITTING OFFICER UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED Check if Continued on Reverse CAUSE OF INJURY DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES 35. Total Days This Facility a* ABSENT SICK DAYS b. OTHER DAYS c* CONV. LV/COOP CARE DAYS d. SUPPLEMENTAL e. INPATIENT TREATMENT RECORD COVER SHEET For use of this form see AR 40-400 the proponent agency is OTSG REGISTER NUMBER SEX FMP FLYING STATUS SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 27a* ADDRESS OF EMERGENCY ADDRESSEE Include ZIP Code 27b. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY SELECTED ADMINISTRATIVE DATA AGE RACE SSN NAME Last First MI RELIGION RATING/ DSG DEPT. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY SELECTED ADMINISTRATIVE DATA AGE RACE SSN NAME Last First MI RELIGION RATING/ DSG DEPT. / BEN LENGTH OF SVC ORGANIZATION BRANCH/CORPS ETS UIC/ZIP HOURS OF ADMISSION GRADE PREVIOUS WARD TYPE CASE CLINIC SERVICE TYPE DISPOSITION DATE OF DISPOSITION TELEPHONE NO. / BEN LENGTH OF SVC ORGANIZATION BRANCH/CORPS ETS UIC/ZIP HOURS OF ADMISSION GRADE PREVIOUS WARD TYPE CASE CLINIC SERVICE TYPE DISPOSITION DATE OF DISPOSITION TELEPHONE NO. DATE OF THIS DATE OF INTIAL ADMISSION REMARKS ADMITTING OFFICER UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED Check if Continued on Reverse CAUSE OF INJURY DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES 35. DATE OF THIS DATE OF INTIAL ADMISSION REMARKS ADMITTING OFFICER UNITS OF WHOLE BLOOD/ COMPONENT TRANSFUSED Check if Continued on Reverse CAUSE OF INJURY DIAGNOSES/OPERATIONS AND SPECIAL PROCEDURES 35. Total Days This Facility a* ABSENT SICK DAYS b. OTHER DAYS c* CONV. LV/COOP CARE DAYS d. SUPPLEMENTAL e. INPATIENT TREATMENT RECORD COVER SHEET For use of this form see AR 40-400 the proponent agency is OTSG REGISTER NUMBER SEX FMP FLYING STATUS SOURCE OF ADMISSION/AUTHORITY FOR ADMISSION NAME/RELATIONSHIP OF EMERGENCY ADDRESSEE 27a* ADDRESS OF EMERGENCY ADDRESSEE Include ZIP Code 27b. NAME AND LOCATION OF MEDICAL TREATMENT FACILITY SELECTED ADMINISTRATIVE DATA AGE RACE SSN NAME Last First MI RELIGION RATING/ DSG DEPT. / BEN LENGTH OF SVC ORGANIZATION BRANCH/CORPS ETS UIC/ZIP HOURS OF ADMISSION GRADE PREVIOUS WARD TYPE CASE CLINIC SERVICE TYPE DISPOSITION DATE OF DISPOSITION TELEPHONE NO. .

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