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FORMULIR BEROBAT

KLINIK ON SITE PT. PERTAMINA GETHERMAL ENERGI


LUMUT BALAI
Nama Pasien

:_______________________________________________________

Tempat/Tgl lahir

:_______________________________________________________

Alamat

:_______________________________________________________

Nama perusahaan

:_______________________________________________________

Bagian/No Pegawai

:_______________________________________________________

Diagnosa

:_______________________________________________________

Terapi & Tindakan

:_______________________________________________________

Lumut Balai,
Petugas Klinik

Pasien

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