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{| | {|style="max-width:700px" | ||
|style="background:teal;" width="100"| | |style="background:teal;" width="100"| | ||
|colspan=2|[[File:Starfleet Medical.png|right|150px|link=Category:Medical Records]] | |width="600" colspan=2|[[File:Starfleet Medical.png|right|150px|link=Category:Medical Records]] | ||
===LAST NAME, FIRST NAME MIDDLE NAME=== | ===LAST NAME, FIRST NAME MIDDLE NAME=== | ||
*'''Patient Reference Number:''' 123-456-789 | *'''Patient Reference Number:''' 123-456-789 |