RS.

HARAPAN BUNDA FORM PENGANTAR

JL. T.UMAR No.181-211 BANDA ACEH
RAWAT INAP

NAMA : .............................................................................................
UMUR : .............................................................................................
JENIS KELAMIN : .............................................................................................
NO. REKAM MEDIS : ............................................................................................
MASUK MELALUI : IGD Rujukan Pengantar RI Poliklinik Spesialis

DIAGNOSIS SEMENTARA : ............................................................................................

RUANGAN : ............................................................................................
PEMBIAYAAN/ASURANSI : ............................................................................................
PETUGAS PEMESAN KAMAR : ............................................................................................
KONFIRMASI PEMESAN KAMAR : ............................................................................................
KETERANGAN : ............................................................................................

Petugas Administrasi Dokter Pengirim

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RS.HARAPAN BUNDA FORM PENGANTAR

JL. T.UMAR No.181-211 BANDA ACEH
RAWAT INAP

NAMA : .............................................................................................
UMUR : .............................................................................................
JENIS KELAMIN : .............................................................................................
NO. REKAM MEDIS : ............................................................................................
MASUK MELALUI : IGD Rujukan Pengantar RI Poliklinik Spesialis

DIAGNOSIS SEMENTARA : ............................................................................................

RUANGAN : ............................................................................................
PEMBIAYAAN/ASURANSI : ............................................................................................
PETUGAS PEMESAN KAMAR : ............................................................................................
KONFIRMASI PEMESAN KAMAR : ............................................................................................
KETERANGAN : ............................................................................................

Petugas Administrasi Dokter Pengirim

( ) ( )