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SURAT KETERANGAN RAWAT INAP PUSKESMAS PENGALIHAN ENOK

PUSKESMAS : PENGALIHAN ENOK

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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Pengalihan Enok, ...........................................2016

Peserta/keluarga

Petugas RITP Puskesmas Pengalihan Enok

Mengetahui,
Dokter Puskesmas

(dr. IRENE SILVIA PURBA)


NIP. 19860613 201412 2 001

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