Anda di halaman 1dari 2

SURAT BUKTI PELAYANAN KB

Yang bertanda tangan di bawah ini :


Nama : .................................................................
Alamat : .................................................................
No. Peserta : ................................................................
Diagnosis : ................................................................
Telah menerima tindakan/pelayanan berupa
1. .................................................................
2. .................................................................
Majalengka, ....................... 201.....
Mengetahui Penerima Pelayanan/Pasien
Petugas Pemberi Pelayanan

............................... ............................................
NIP.

SURAT BUKTI PELAYANAN KB


Yang bertanda tangan di bawah ini :
Nama : .................................................................
Alamat : .................................................................
No. Peserta : ................................................................
Diagnosis : ................................................................
Telah menerima tindakan/pelayanan berupa
1. .................................................................
2. .................................................................
Majalengka, ....................... 201.....
Mengetahui Penerima Pelayanan/Pasien
Petugas Pemberi Pelayanan

............................... ............................................
NIP.

SURAT BUKTI PELAYANAN KB

Yang bertanda tangan di bawah ini :


Nama : .................................................................
Alamat : .................................................................
No. Peserta : ................................................................
Diagnosis : ................................................................
Telah menerima tindakan/pelayanan berupa
1. .................................................................
2. .................................................................
Majalengka, ....................... 201.....
Mengetahui Penerima Pelayanan/Pasien
Petugas Pemberi Pelayanan

............................... ............................................
NIP.
SURAT BUKTI PELAYANAN KB

Yang bertanda tangan di bawah ini :


Nama : .................................................................
Alamat : .................................................................
No. Peserta : ................................................................
Diagnosis : ................................................................
Telah menerima tindakan/pelayanan berupa
1. .................................................................
2. .................................................................

Majalengka, ....................... 201.....


Mengetahui Penerima Pelayanan/Pasien
Petugas Pemberi Pelayanan

............................... ............................................
NIP.

SURAT BUKTI PELAYANAN KB

Yang bertanda tangan di bawah ini :


Nama : .................................................................
Alamat : .................................................................
No. Peserta : ................................................................
Diagnosis : ................................................................
Telah menerima tindakan/pelayanan berupa
1. .................................................................
2. .................................................................

Majalengka, ....................... 201.....


Mengetahui Penerima Pelayanan/Pasien
Petugas Pemberi Pelayanan

............................... ............................................
NIP.

Anda mungkin juga menyukai