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PEMERINTAH KABUPATEN PURBALINGGA

PEMERINTAH KABUPATEN PURBALINGGA

DINAS KESEHATAN
UPTD PUSKESMAS BOJONGSARI

DINAS KESEHATAN
UPTD PUSKESMAS BOJONGSARI

Jl. Raya Bojongsari No. 28 Telp. (0281) 6596981. Kode Pos. 53362

Jl. Raya Bojongsari No. 28 Telp. (0281) 6596981. Kode Pos. 53362

Umum/ Askes/ SKTM/ Jampersal/ Jamkesmas/ Jamkesda/ Jamkesdakin

Umum/ Askes/ SKTM/ Jampersal/ Jamkesmas/ Jamkesda/ Jamkesdakin

No. : ............................................................. Tgl.

No. : ............................................................. Tgl.

Diagnosa:

Diagnosa:

TD: ......../........... mmHg

R/

R/

Tindakan :

Tindakan :

Biaya

Biaya

TD: ......../........... mmHg

Yang Memberi Resep,

Yang Memberi Obat,

Yang Memberi Resep,

Yang Memberi Obat,

( ......................................... )

( ......................................... )

( ......................................... )

( ......................................... )

Nama

: ..........................................................................

Nama

: ..........................................................................

Umur

: ..........................................................................

Umur

: ..........................................................................

No. Reg. : ..........................................................................

No. Reg. : ..........................................................................

Alamat

Alamat

: ..........................................................................

: ..........................................................................

PEMERINTAH KABUPATEN PURBALINGGA

PEMERINTAH KABUPATEN PURBALINGGA

DINAS KESEHATAN
UPTD PUSKESMAS BOJONGSARI

DINAS KESEHATAN
UPTD PUSKESMAS BOJONGSARI

Jl. Raya Bojongsari No. 28 Telp. (0281) 6596981. Kode Pos. 53362

Jl. Raya Bojongsari No. 28 Telp. (0281) 6596981. Kode Pos. 53362

Umum/ Askes/ SKTM/ Jampersal/ Jamkesmas/ Jamkesda/ Jamkesdakin

Umum/ Askes/ SKTM/ Jampersal/ Jamkesmas/ Jamkesda/ Jamkesdakin

No. : ............................................................. Tgl.

No. : ............................................................. Tgl.

Diagnosa:

Diagnosa:

TD: ......../........... mmHg

R/

R/

Tindakan :

Tindakan :

Biaya

Biaya

TD: ......../........... mmHg

Yang Memberi Resep,

Yang Memberi Obat,

Yang Memberi Resep,

Yang Memberi Obat,

( ......................................... )

( ......................................... )

( ......................................... )

( ......................................... )

Nama

: ..........................................................................

Nama

: ..........................................................................

Umur

: ..........................................................................

Umur

: ..........................................................................

No. Reg. : ..........................................................................

No. Reg. : ..........................................................................

Alamat

Alamat

: ..........................................................................

: ..........................................................................