医患纠纷调解申请表

医患纠纷调解申请表（患方）

申请人基本情况患者姓名：                 性别：        出生日期：                 患方申请人：                                                        联系电话：                                                          （）法定代理人/（）委托代理人：                                     联系电话：                                                          户籍地址或经常居住地：

案件简要情况医疗机构：                                                          索赔金额：                                                          索赔明细：                                                                                                                              争议要点及理由：

提交材料目录（）调解申请表                            （）身份证明复印件（）授权委托书                            （）案情陈述及请求（）病历资料复印件                        （）鉴定意见书复印件

申请人承诺：本人保证提交的上述材料属实，如有不实，愿承担法律责任。                                申请人或代理人（签名）：                                                   年    月   日