PEMERINTAH KABUPATEN PANDEGLANG

DINAS KESEHATAN
UPT PUSKESMAS CIBALIUNG
Jl. Raya Cimanggu-Cibaliung Km. 10 Desa Sukajadi Pos. 42285 Call Center: 081517298900

VISITE DOKTER
NO RM : ...................................................................... JK :.................................................
NAMA :...................................................................... STATUS :.................................................
UMUR :...................................................................... NO.JAMINAN :.................................................
ALAMAT :..................................................................... TGL MASUK :.................................................
DIAGNOSA :.... RUANG :.................................

HARI / INTRUKSI TTD DOKTER

JAM HASIL PEMERIKSAAN DOKTER
TGL DOKTER NAMA