01
FORMULIR PENDAFTARAN RAWAT INAP / ONE DAY CARE
Semua bagian harus diisi
No. Rekam Medis
No. Register : __________________________________
A. IDENTITAS PASIEN ( bagian ini harus lengkap dan mohon diisi pasien )
Nama depan (sesuai KTP)
: ______________________________________________________
: __________________________________________________________________________________
: __________________________________Agama
Laki-laki
Perempuan
: ____________________________________
: ________________________________
Kec. ________________________
Telepon. _____________________
HP.___________________________
: ________________________________
Pendidikan terakhir
: __________________________________________________________________________________
Pekerjaan / bagian
: __________________________________________________________________________________
Alamat kantor
: __________________________________________________________________________________
Warga negara
: __________________________________________________________________________________
: _____________
bulan : __________________
tahun : _________
: __________________________________________________________________________________
: __________________________________________________________________________________
: __________________________________________________________________________________
Kelurahan
: ________________________________
Kec. ________________________
Kota/wilayah
: ________________________________
Telepon. _____________________
: ________________________________
HP.___________________________
Alamat kantor
: __________________________________________________________________________________
Pekerjaan / bagian
: __________________________________________________________________________________
: _____________
Kamar
: ___________ Lantai
: _____________________
Tanggal masuk
: _____________
Jam
: _____________________
DPJP
: __________________________________________________________________________________
IRJ
Jaminan kesehatan
GAKIN/SKTM
Rujukan :
Dr. Royal Progress
: _____________________
ASKES
JAMSOSTEK
Rumah Sakit
: _____________________
Lainnya
Bidan
: _____________________
Perusahaan rekanan
: _____________________
Yayasan
: _____________________
Progress Group
: _____________________
Cara pembayaran
Pribadi
Jaminan : ______________________________________________________
Surat jaminan
Surat rujukan
Ya
Tidak
Ya
Tidak
( )
Nama lengkap
Tanda tangan petugas admission
( .)
Nama lengkap