KITIR

PEMERINTAH KABUPATEN LOMBOK TIMUR
DINAS KESEHATAN
PUSKESMAS DASAN LEKONG
Jalan Raya Masbagik - Dasan Lekong
SLIP PENARIKAN / PEMBAYARAN

PERSALINAN
SL
Nama
: ..................................
Umur
: ............... Th / Bln
Nama
Alamat
: ..................................
Diagnosa
: ..................................
Alamat
1. Jenis Pelayanan Umum
1. Jenis Pelayanan
1. Tindakan
1.
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
2. Laboratorium
2. Laboratorium
a. ......................................................
Rp ..............................
a.
b. ......................................................
Rp ..............................
b.
c. ......................................................
Rp ..............................
c.
d. ......................................................
Rp ..............................
d.
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Mengetahui
Mengeta
Kepala Puskesmas Dasan Lekong
Bendahara Penerima
Kepala Puskesmas D
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
dr. H. Samsu
NIP. 19681126 19

DINAS KESEHATAN

PERSALINAN
SLIP PENAR
PE
: ..................................
Umur
: ............... Th / Bln
Nama
: ..................................
Diagnosa
: ..................................
Alamat
Tindakan
1.
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
2. Laboratorium
2. Laboratorium
......................................................
Rp ..............................
a.
......................................................
Rp ..............................
b.
......................................................
Rp ..............................
c.
......................................................
Rp ..............................
d.
JUMLAH
Rp ..............................
Dasan Lekong,
JUMLAH
2016
Mengetahui
Mengetahui
Bendahara Penerima
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
Kepala Puskesmas Dasan Lekon
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003

DINAS KESEHATAN

PERSALINAN
: ..................................
Umur
: ............... Th / Bln
: ..................................
Diagnosa
: ..................................

Tindakan
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
2. Laboratorium
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Mengetahui
Bendahara Penerima
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001

DINAS KESEHATAN

RAWAT INAP (KIA)
SL
Nama
: ..................................
Umur
: ............... Th / Bln
Nama
Alamat
: ..................................
Diagnosa
: ..................................
Alamat
1. Jenis Pelayanan
1. Kamar ............ x 35.000
Rp ..............................
2. Tindakan
1.
2.
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
3. Visite Dokter
Rp15,000
3.
4. Asuhan Kebidanan
Rp10,000
4.
2. Laboratorium
2. Laboratorium
a. ......................................................
Rp ..............................
a.
b. ......................................................
Rp ..............................
b.
c. ......................................................
Rp ..............................
c.
d. ......................................................
Rp ..............................
d.
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Mengetahui
Mengeta
Bendahara Penerima
Kepala Puskesmas D
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
dr. H. Samsu
NIP. 19681126 19
DINAS KESEHATAN

RAWAT INAP (KIA)
SL
Nama
: ..................................
Umur
: ............... Th / Bln
Nama
Alamat
: ..................................
Diagnosa
: ..................................
Alamat
1. Jenis Pelayanan
1. Kamar ............ x 35.000
Rp ..............................
2. Tindakan
1.
2.
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
3. Visite Dokter
Rp15,000
3.
4. Asuhan Kebidanan
Rp10,000
4.
2. Laboratorium
2. Laboratorium
a. ......................................................
Rp ..............................
a.
b. ......................................................
Rp ..............................
b.
c. ......................................................
Rp ..............................
c.
d. ......................................................
Rp ..............................
d.
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Bendahara Penerima
Siti Sundari
NIP. 19610525 198010 2 001

DINAS KESEHATAN

RAWAT INAP (KIA)
SLIP PENAR
RAW
: ..................................
Umur
: ............... Th / Bln
Nama
: ..................................
Diagnosa
: ..................................
Alamat
Kamar ............ x 35.000
Rp ..............................
Tindakan
1.
2.
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
Visite Dokter
Rp15,000
3.
Asuhan Kebidanan
Rp10,000
4.
2. Laboratorium
2. Laboratorium
......................................................
Rp ..............................
a.
......................................................
Rp ..............................
b.
......................................................
Rp ..............................
c.
......................................................
Rp ..............................
d.
JUMLAH
Rp ..............................
Dasan Lekong,
JUMLAH
2016
Mengetahui
Mengetahui
Bendahara Penerima
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
Kepala Puskesmas Dasan Lekon
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
DINAS KESEHATAN

RAWAT INAP (KIA)
SLIP PENAR
RAW
: ..................................
Umur
: ............... Th / Bln
Nama
: ..................................
Diagnosa
: ..................................
Alamat
Kamar ............ x 35.000
Rp ..............................
Tindakan
1.
2.
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
Visite Dokter
Rp15,000
3.
Asuhan Kebidanan
Rp10,000
4.
2. Laboratorium
2. Laboratorium
......................................................
Rp ..............................
a.
......................................................
Rp ..............................
b.
......................................................
Rp ..............................
c.
......................................................
Rp ..............................
d.
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Bendahara Penerima
Siti Sundari
NIP. 19610525 198010 2 001
JUMLAH

DINAS KESEHATAN

RAWAT INAP (KIA)
: ..................................
Umur
: ............... Th / Bln
: ..................................
Diagnosa
: ..................................

Kamar ............ x 35.000
Rp ..............................
Tindakan
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
Visite Dokter
Rp15,000
Asuhan Kebidanan
Rp10,000
2. Laboratorium
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Mengetahui
Bendahara Penerima
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
DINAS KESEHATAN

RAWAT INAP (KIA)
: ..................................
Umur
: ............... Th / Bln
: ..................................
Diagnosa
: ..................................

Kamar ............ x 35.000
Rp ..............................
Tindakan
a. ........................................................... Rp ..............................
b. ........................................................... Rp ..............................
c. ........................................................... Rp ..............................
d. ........................................................... Rp ..............................
Visite Dokter
Rp15,000
Asuhan Kebidanan
Rp10,000
2. Laboratorium
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Bendahara Penerima
Siti Sundari
NIP. 19610525 198010 2 001

DINAS KESEHATAN

RAWAT JALAN (KIA)
SLIP P
Nama
: ..................................
Umur
: ............... Th / Bln
Nama
Alamat
: ..................................
Diagnosa
: ..................................
Alamat
1. Jenis Pelayanan Um
a. ......................................................
Rp ..............................
a.
b. ......................................................
Rp ..............................
b.
c. ......................................................
Rp ..............................
c.
d. ......................................................
Rp ..............................
d.
e. ......................................................
Rp ..............................
e.
f. ......................................................
Rp ..............................
f.
2. Laboratorium
2. Laboratorium
a. ......................................................
Rp ..............................
a.
b. ......................................................
Rp ..............................
b.
c. ......................................................
Rp ..............................
c.
d. ......................................................
Rp ..............................
d.
e. ......................................................
Rp ..............................
e.
f. ......................................................
Rp ..............................
f.
JUMLAH
Rp ..............................
Dasan Lekong,
JUM
2016
Mengetahui
Mengetahui
Bendahara Penerima
Kepala Puskesmas Dasan
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
dr. H. Samsul Bah

NIP. 19681126 199903

DINAS KESEHATAN

RAWAT JALAN (KIA)
SLIP PENARIKA
RAWAT
: ..................................
Umur
: ............... Th / Bln
Nama
: ..................................
Diagnosa
: ..................................
Alamat
s Pelayanan Umum
......................................................
Rp ..............................
a.
......................................................
Rp ..............................
b.
......................................................
Rp ..............................
c.
......................................................
Rp ..............................
d.
......................................................
Rp ..............................
e.
......................................................
Rp ..............................
f.
oratorium
2. Laboratorium
......................................................
Rp ..............................
a.
......................................................
Rp ..............................
b.
......................................................
Rp ..............................
c.
......................................................
Rp ..............................
d.
......................................................
Rp ..............................
e.
......................................................
Rp ..............................
f.
JUMLAH
Rp ..............................
Dasan Lekong,
JUMLAH
2016
Mengetahui
Mengetahui
la Puskesmas Dasan Lekong
Bendahara Penerima
dr. H. Samsul Bahri

19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001
dr. H. Samsul Bahri

NIP. 19681126 199903 1 003

DINAS KESEHATAN

RAWAT JALAN (KIA)
: ..................................
Umur
: ............... Th / Bln
: ..................................
Diagnosa
: ..................................
s Pelayanan Umum
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
oratorium
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
......................................................
Rp ..............................
JUMLAH
Rp ..............................
Dasan Lekong,
2016
Mengetahui
la Puskesmas Dasan Lekong
Bendahara Penerima
dr. H. Samsul Bahri

19681126 199903 1 003
Siti Sundari
NIP. 19610525 198010 2 001

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PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

Kepala Puskesmas Dasan Lekong

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

1. Jenis Pelayanan Umum

Kepala Puskesmas Dasan Lekong

dr. H. Samsul Bahri

Kepala Puskesmas Dasan Lekon

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

1. Kamar ............ x 35.000

Kepala Puskesmas Dasan Lekong

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

1. Kamar ............ x 35.000

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

1. Jenis Pelayanan Umum

Kamar ............ x 35.000

Kepala Puskesmas Dasan Lekong

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

Kepala Puskesmas Dasan Lekon

dr. H. Samsul Bahri

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

1. Jenis Pelayanan Umum

Kamar ............ x 35.000

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

Kepala Puskesmas Dasan Lekong

Kepala Puskesmas Dasan

dr. H. Samsul Bahri

dr. H. Samsul Bah

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN

1. Jenis Pelayanan Umum

la Puskesmas Dasan Lekong

Kepala Puskesmas Dasan Lekong

dr. H. Samsul Bahri

dr. H. Samsul Bahri

PEMERINTAH KABUPATEN LOMBOK TIMUR

SLIP PENARIKAN / PEMBAYARAN