BON PEMINJAMAN

DOKUMEN REKAM MEDIS

BON PEMINJAMAN
DOKUMEN REKAM MEDIS

NO. RM

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

NO. RM

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

NAMA PX.

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

NAMA PX.

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

TGL PINJAM

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

TGL PINJAM

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

TGL KEMBALI

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

TGL KEMBALI

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

NAMA PEMINJAM : ................................................................

NAMA PEMINJAM : ................................................................

RUANG

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

RUANG

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

KETERANGAN

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

KETERANGAN

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

HARAP SEGERA DIKEMBALIKAN

HARAP SEGERA DIKEMBALIKAN

JANGAN MELETAKKAN DI SEMBARANG TEMPAT

JANGAN MELETAKKAN DI SEMBARANG TEMPAT

Surabaya, ..............
Peminjam

Petugas RM

Surabaya, ..............
Peminjam

Petugas RM

Tandatangan

Tandatangan

Tandatangan

Tandatangan

BON PEMINJAMAN
DOKUMEN REKAM MEDIS

BON PEMINJAMAN
DOKUMEN REKAM MEDIS

NO. RM

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

NO. RM

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

NAMA PX.

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

NAMA PX.

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

TGL PINJAM

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

TGL PINJAM

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

TGL KEMBALI

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

TGL KEMBALI

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

NAMA PEMINJAM : ................................................................

NAMA PEMINJAM : ................................................................

RUANG

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

RUANG

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

KETERANGAN

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

KETERANGAN

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

HARAP SEGERA DIKEMBALIKAN

HARAP SEGERA DIKEMBALIKAN

JANGAN MELETAKKAN DI SEMBARANG TEMPAT

JANGAN MELETAKKAN DI SEMBARANG TEMPAT

Surabaya, ..............
Peminjam

Petugas RM

Surabaya, ..............
Peminjam

Petugas RM

Tandatangan

Tandatangan

Tandatangan

Tandatangan

BON PEMINJAMAN
DOKUMEN REKAM MEDIS

BON PEMINJAMAN
DOKUMEN REKAM MEDIS

NO. RM

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

NO. RM

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

NAMA PX.

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

NAMA PX.

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

TGL PINJAM

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

TGL PINJAM

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

TGL KEMBALI

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

TGL KEMBALI

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

NAMA PEMINJAM : ................................................................

NAMA PEMINJAM : ................................................................

RUANG

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

RUANG

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

KETERANGAN

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

KETERANGAN

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

HARAP SEGERA DIKEMBALIKAN

HARAP SEGERA DIKEMBALIKAN

JANGAN MELETAKKAN DI SEMBARANG TEMPAT

JANGAN MELETAKKAN DI SEMBARANG TEMPAT

Surabaya, ..............
Peminjam

Petugas RM

Surabaya, ..............
Peminjam

Petugas RM

Tandatangan

Tandatangan

Tandatangan

Tandatangan