Kau
|ص. ب. 80215 ، جدة 21589 |إيميل : med.vd.ca@kau.edu.sa |فاكس : 6408341 |( 6408468 / 6401000 |
|P.O. Box 80215, Jeddah 21589 |E-mail: med.vd.ca@kau.edu.sa | Fax: 6408341 | ( 6408468 / 6401000 |
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INTERNS REQUEST FORM
DATE OF REQUEST: ____彟彟彟彟彟匍啔䕄呎丠⹏›彟彟彟彟彟彟彟彟彟य़䕓䥒䱁丠⹏›张彟彟彟彟彟彟彟彟彟不䵁㩅张彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟䔍䴭䥁㩌张彟彟彟彟彟彟彟彟彟彟彟彟彟†位䥂䕌丠⹏›彟彟彟彟彟彟彟彟彟敄牡䤠瑮牥潃牯楤慮潴Ⱳ弍彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟彟__________
STUDENT NO.: ___________________ SERIAL NO.: ___________________
NAME: _____________________________________________________________
E-MAIL: ___________________________ MOBILE NO.: __________________
Dear Intern Coordinator,
______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
|ORIGINAL SCHEDULE |REQUESTED CHANGES |
|ROTATION |HOSPITAL |PERIOD |ROTATION |HOSPITAL |PERIOD |
| | | | | | |
| | | | | | |
| | | | | | |
(Attached documents, if any)
Please refer to the FAQ’s & change policy before requesting. Changes are not allowed from any affiliated hospital.
( I acknowledge that all data are true and correct. I am fully responsible for any
disciplinary action if any information was false.
Respond: ( Approved ( Disapproved: __________________________________
___________________________________________
( Needs documentation
( For discussion
( Others: _____________________________________________________
_________________________________________________________
Dr. Rani G Ahmad
House Officer Supervisor
HO -
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