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Personuppgifter Namn Personnummer/samordningsnummerAdress Telefon Postnummer, ort  Fyll i vilket vrdenhet det gller: Vrdenhet(hlsocentral/klinik) 1Frn och med (rtal eller datum)Vrdenhet(hlsocentral/klinik) 2Frn och med (rtal eller datum)Vrdenhet(hlsocentral/klinik) 3Frn och med (rtal eller datum)Vrdenhet(hlsocentral/klinik) 4Frn och med (rtal eller datum)Vrdenhet(hlsocentral/klinik) 5Frn och med (rtal eller datum)Vrdenhet(hlsocentral/klinik) 6Frn och med (rtal eller datum) Om du vill ha svar p om ngon speciell person/er varit inne i din journal ange namnen/namnet hr: Fr- och efternamn Fr- och efternamn Fr- och efternamn Fr- och efternamn Fr- och efternamn Fr- och efternamn  Underskrift UnderskriftDatum  Ytterligare upplysningar kring rendet kan fs frn berrd verksamhetschef. Fr ytterligare frgor kring loggkontroller var vnlig kontakta Region Gvleborgs dataskyddsombud, dataskyddsombud@regiongavleborg.se. Ifylld blankett skickas till: Region Gvleborg 801 88 Gvle Utskriften skickas i rekommenderat brev till din folkbokfringsadress.      Formulr  PAGE 2( NUMPAGES \* Arabic \* MERGEFORMAT 2)Dokumentnamn: Loggkontroll - Blankett fr patient. 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