PEMERINTAH KABUPATEN TEMANGGUNG

DINAS KESEHATAN

PUSKESMAS BEJEN
Jl. Raya Sukorejo , Kecamatan Bejen, Kode pos 56258
Telp. 0294 3563020

SURAT KONTROL

Nama Penderita

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

Umur

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

Alamat

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

No. RM

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

Dirawat di Puskesmas Rawat Inap Bejen Tanggal :..............................................

Diagnosa

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

Therapi yang diberikan :....................................................................................

:....................................................................................
:....................................................................................
:....................................................................................
:....................................................................................
Tanggal kontrol

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

Dokter yang merawat

___________________________
NIP.