JAM MASUK :
Yang bertanda tangan dibawah ini Petugas RITP Puskesmas Pengalihan Enok
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Nama Penderita
No. Kartu
Umur
Status Gakin
Alamat
Diagnosa
Telah dirawat sejak tanggal
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Peserta/keluarga
Mengetahui,
Dokter Puskesmas