北京市医疗纠纷人民调解委员会

医疗纠纷调解患方申请书

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第二篇：医疗纠纷调解申请书(患方)

医疗纠纷调解申请书（患方）

一、患方当事人基本情况                                            

                                                                                

 

   患者姓名                       性别                           年龄                                          

       

   身份证号                       电话              家庭住址                                   

   委托代理人姓名                 电话              与患者关系                        

     

二、申请调解的纠纷事实：                                          

                                                                   

                                                                 

                                                                

                                                                

                                                                  

                                                              

三、申请调解的争议要点及理由：                                   

                                                                  

                                                                        

                                                                 

                                                                  

                                                                

四、申请调解的赔偿金额：                                        

特申请鞍山市铁东地区医疗纠纷调解委员会予以调解。

申请人：                             申请日期：   年   月   日