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CAIRAN KE :................................ CAIRAN KE :................................

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Ket: Ket:

NAMA :................................ NAMA :................................

NO. RM :................................ NO. RM :................................

TANGGAL :................................ TANGGAL :................................

CAIRAN KE :................................ CAIRAN KE :................................

JENIS CAIRAN :................................ JENIS CAIRAN :................................

OBAT :................................ OBAT :................................

TETES / MENIT :................................ TETES / MENIT :................................

Ket: Ket:

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