Form Penyerahan

Form Penyerahan Jasa Pelayanan Laundry & Nota Tagihan Jasa Laundry
( pakaian / linen milik pasien & keluarga pasien )

Nama Pasien : ....................................................................... Nota Nomer ..............................................................

Nomer RM : .......................................................................
Ruang Perawatan : ....................................................................... Terima Kotor
Alamat : ........................................................................ Tanggal ......................................
Nomer Telepon : ........................................................................ Jam ......................................

Jenis
Dewasa( Jumlah Layanan :
Biaya
No. Jenis Pakaian / Linen D)/ (potong/pcs Cuci (C),
( Rp/ pcs )
Anak(A) ) Kering (K),
Setrika (S)

Jumlah Total Linen (pcs) & Biaya (Rp) ....................................... ......................

Semarang, ........, ......................................, ................

Unit Laundry : Ruangan / Unit : Pelanggan :

( ...................................... ) ( ........................................ ) ( ......................................................

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 Form Penyerahan

ihan Jasa Laundry

pasien )

.................................................................

Kirim Bersih
........................................
........................................

Jumlah Biaya
( Rp )

.............................

..............
Pelanggan :

............................................. )

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 Form Service

Form Permintaan Jasa Pelayanan Laundry ( Kirim Linen Kotor )

( pakaian / linen milik pasien & keluarga pasien )

Nama Pasien : ...................................................................... Nota Nomer ......................................................

Nomer RM : ......................................................................
Ruang Perawatan : ...................................................................... Terima
Alamat : ....................................................................... Tanggal ...................................
Nomer Telepon : ...................................................................... Jam ...................................

Jenis Layanan :
Keterangan / Informasi / Catatan
Dewasa(D)/ Jumlah Cuci (C),
No. Jenis Pakaian / Linen (kondisi, tanda, warna linen,
Anak(A) (potong/pcs) Kering (K),
merk)
Setrika (S)

Jumlah Total Linen (potong/pcs ) ...................................

Semarang, ........, ......................................, ................

Unit Laundry : Ruangan / Unit : Pelanggan :

( ....................................... ) ( ........................................... ) ( .................................................

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 Form Service

m Linen Kotor )
pasien )

......................................................

Selesai
......................................
.....................................

Keterangan / Informasi / Catatan

(kondisi, tanda, warna linen,
merk)

................
Pelanggan :

........................................... )

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