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["（様式第2号）"]
["通 院 証 明 書"]
[]
[1,"患者氏名"]
[2,"患者住所","上水内郡信濃町大字"]
[3,"疾患名"]
[4,"治療の状況"]
[]
["月別通院日及び回数","月別","通院日","回数"]
[null,"月"]
[null,"月"]
[null,"月"]
[null,"月"]
[]
[null,"上記のとおり相違ないことを証明します。"]
[null,null,"平成　　　　年　　　　月　　　　日"]
[null,null,"医療機関名","印"]

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