KLINIK ALAM SUTRA MEDIKA

KODIM 0611 GARUT

No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

PERMINTAAN PEMERIKSAAN RONTGEN

Nomor : / / / 2015

Nama :................................................... umur :.......................... Thn

Suami / Istri / Anak dari :..................................................................................................................................
Pangkat / NRP / NBI / NIP :................................................ Kesatuan :...........................................................
Dari Ruang / Poliklinik :..................................................................................................................................
Pemeriksaan rontgen terakhir tanggal ............................. Nomor ...................... jenis ...........................................
Pemeriksaan rontgenologies yang diminta .............................................................................................................
.................................................................................................................................................................................
.................................................................................................................................................................................
Garut, .................................. 20.....
Dokter yang meminta

(..............................................)
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

SURAT KETERANGAN SEHAT/TIDAK SEHAT

Nomor : / / / 2015

Yang bertanda tangan dibawah ini, menerangkan:

Nama : . .............................................................................................................................
umur : . ............................................................................................................................
Pangkat / Gol : . .............................................................................................................................
NRP / NIP : . .............................................................................................................................
Kesatuan : . .............................................................................................................................
Nama Suami / Ayah / Ibu : . .............................................................................................................................
Pangkat / Gol : . .............................................................................................................................

Menerangkan bahwa orang tersebut benar-benar sehat/sakit.

Untuk keperluan. _____________________
Garut, .......................... 20.....
Yang memeriksa/merawat

Nama : .....................
Pangkat/Gol : .....................
NRP/NIP : .....................
Jabatan : .....................
Kesatuan : .....................
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

SURAT KETERANGAN SEHAT BADAN

Nomor : / / / 2015

Yang bertanda tangan di bawah ini Dokter Pemerintah Kabupaten Garut menerankan dengan
sesungguhnya telah memeriksa kesehatan :
Nama :. ____________________________ Berat Badan : kg
Umur :. _____________________________ Tinggi Badan : cm
Pangkat/golongan :. ____________________________ Tekanan Darah : mmhg
Nrp/nip :. _____________________________ HB : gram%
Alamat :. _____________________________

Berpendapat bahwa hasil pemeriksan jasmaninya sehat untuk :. ______________________________________

_________________________________________________________________________________________

Tanda tangan Garut,...........................20......

Yang diperiksa Dokter yang memeriksa

(...............................................) (..............................................)
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

SURAT ISTIRAHAT SAKIT/KERJA RINGAN

Nomor : / IST / / 2015

Yang bertanda tangan dibawah ini, menerangkan:

Nama : . .............................................................................................
Umur : . .............................................................................................
Alamat : . .............................................................................................
Pangkat/Golongan : . .............................................................................................
NIP : . .............................................................................................

Sehubungan dengan sakitnya, memerlukan istirahat/kerja ringan

selama.............. (.................................) hari.
Terhitung mulai tanggal.......................................... s/d .......................................

Garut,.....................................20 ....
Dokter yang memeriksa/merawat

(..............................................)
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

SURAT PENGANTAR RUJUKAN PASIEN

Nomor : / / / 2015

Kepada
Yth...............................................................
.....................................................................

Mohon konsul dan penanganan selanjutnya pada pasien :

Nama : .............................................................................................
Umur : .............................................................................................
Alamat : .............................................................................................
Keterangan klinis : .......................................................................................
.......................................................................................
Diagnosa klinis : .......................................................................................
.......................................................................................
Telah kami berikan therapi :
- . ..............................................................................
- ...............................................................................
- . ..............................................................................
- . ..............................................................................

Atas bantuannya, kami ucapkan terima kasih

Garut,.....................................20 ....
Dokter yang memeriksa/merawat

(..............................................)
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

PERMINTAAN PEMERIKSAAN LABORATORIUM

Nomor : / / / 2015

Nama : . ............................................... umur : ............... Thn

Dokter yang meminta : . ............................................... Ruang :......................
Diagnosa / ket. Klinik : . ...................................................................................

Hematologi Urine
Kimia Darah
o Hemoglobin o Rutin
o Ureum
o Leukosit o Tes Kehamilan
o Kreatinin
o Hitung Jenis o ........................
o Asam Urat
o LED
o Kolesterol
o Eritrosit
o HDL kolesterol
o Trombosit Feses
o LDL kolesterol
o Hemotokrit
o Trigliserida o Rutin
o Gol. Darah
o Bilirubin T/D o ........................
o W. Perdarahan
o SGOT
o W. Pembekuan
o SGPT
o Malaria Serologi
o Gula Darah Puasa
o ............
o Gula Darah 2 jam PP
o HBs Ag o Widal
o Gula darah sewaktu
o ........................
o ....................

Garut,.....................................20 ....

(..............................................)
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

Nama :. _________________________________
Umur :. _________________________________
Jenis kelamin : Laki-laki / Perempuan
Pangkat / Golongan :. ________________________________
NRP :. _________________________________
Kesatuan :. _________________________________
Alamat :. _________________________________
Data khusus : Alergi .___________________________
Keluhan
No Tanggal Diagnosa Therapy
Pemeriksaan fisik
 Keluhan
No Tanggal Diagnosa Therapy
Pemeriksaan fisik
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

KARTU BEROBAT

No.Registrasi:
Nama :
Umur :. ....................... Thn ............................ Bln
Jenis kelamin: Laki-laki / Perempuan
Pangkat/NRP:. .....................................................................................
Alamat :. .....................................................................................

" KARTU JANGAN HILANG DAN HARAP DI BAWA SETIAP KALI BEROBAT
 KLINIK ALAM SUTRA MEDIKA
KODIM 0611 GARUT
No. Izin Praktek 503/1463/11-IOK/BPMPT/2015
Jl.Veteran No.1 Kel. Pakuwon Garut Kota Kab. Garut

KARTU PESERTA KB

Nama Peserta KB :. ...........................................................................

Tgl. Lahir / Umur Istri :. .................................................................... Thn
Nama Suami / Istri
Pangkat/NRP
Alamat Peserta KB
Tahapan KS
Status Peserta Jaminan :
Nomor Seri Kartu
Nama Faskes KB
Nomor Kode Faskes KB:
:. ............................................................................
:. ............................................................................
: .............................................................................
:. ............................................................................
: .............................................................................
Peserta JKN:
Penerima Bantuan Iuran
Bukan Penerima Bantuan Iuran
Bukan Peserta JKN
:
:. ............................................................................

Garut, ............................ 20.......

Penanggung jawab Faskes KB /
Praktik Dokter / Praktik Bidan Mandiri,

(.....................................................................)
Metode Kontrasepsi : .............................................................
Tgl / Bln / Thn Mulai Dipakai :
Tgl / Bln / Thn Dicabut / Dilepas :
(Khusus Implan / IUD)

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