RS. BHAKTI DARMA HUSADA Surabaya, .......................

/2016
Jl. kendung no. 115 – 117 Surabaya
Telp. (031) 7409135

- Sejawat Yth.
Pemeriksaan kami pada penderita :
Nama : ______________________________________________________________Laki-laki/Perempuan
Umur : ____________ bulan/tahun. Jabatan : _________________________________________________
Waktu ini kami dapatkan : ________________________________________________________________
I. Anamnese
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II. Pemeriksaan THT

- Telinga :
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- Hidung :
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- Tenggorokan :
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III. Diagnosa : ......................................................................................................................................................................

IV. Terapi : ..........................................................................................................................................................................
V. Advis Terapi : ................................................................................................................................................................

BTK
Hormat kami,

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