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SURAT PENGANTAR DIRAWAT

NOMOR REKAM MEDIS : __________________________________________________


NAMA : __________________________________________________
TANGGAL LAHIR : __________________________________________________
ALASAN MASUK RS : __________________________________________________
INDIKASI MASUK RS : __________________________________________________
DIAGNOSA KERJA : __________________________________________________
DOKTER PJP : __________________________________________________
RUANG / KELAS : __________________________________________________

HARI & TGL : ______________________


JAM : ______________________

DOKTER : ______________________

SURAT PENGANTAR DIRAWAT

NOMOR REKAM MEDIS : __________________________________________________


NAMA : __________________________________________________
TANGGAL LAHIR : __________________________________________________
ALASAN MASUK RS : __________________________________________________
INDIKASI MASUK RS : __________________________________________________
DIAGNOSA KERJA : __________________________________________________
DOKTER PJP : __________________________________________________
RUANG / KELAS : __________________________________________________

HARI & TGL : ______________________


JAM : ______________________

DOKTER : ______________________

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