[PROVISIONAL TRANSLATION FROM PERSIAN]

 

[Translator’s notes appear in square brackets]

[Personal information has been redacted.]

 

Form for Patients with Chronic Diseases Covered by the Social Services Organization

Drug card for senior patients receiving pension

 

[Illegible] [Name:]

[Illegible] [Surname:]

[Illegible] [Gender] Male:      Female:

[Illegible] [Marital status] Single:      Married:

[Place for photo]

Date of birth: -----

Place of birth: -----

Place of issuance of birth certificate:

Religion: -----

Occupation: -----

Place of work: -----

Address and telephone:

Diagnosis: -----

Date: -----

Notes: Blood pressure – Tests: -----

Medications:      Dosage       Number prescribed       Logbook’s serial number -----

Seal and signature of the physician: -----

Seal and signature of the technician and seal of the pharmacy: -----