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PEMERINTAH KABUPATEN PURWAKARTA

DINAS KESEHATAN
UPTD PUSKESMAS BOJONG
Jalan Raya Bojong – Sawit Km 31 Purwakarta Phone : 0264 2631344

LEMBAR BUKTI PELAYANAN AMBULANCE


PASIEN ASKES MASYARAKAT MISKIN

PUSKESMAS BOJONG KABUPATEN PURWAKARTA

Nama Pasien : ..............................................................................................


Jenis Kelamin : ..............................................................................................
Umur : ..............................................................................................
No Identitas : .............................................................................................
Diagnosa : ..............................................................................................
Pelayanan Ambulance : ..............................................................................................
Nomor Kendaraan : .........................................................
Tanggal / Jam : .........................................................
Rumah Sakit Tujuan : .........................................................

Puskesmas Pengirim Pasien / Keluarga Pasien

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Rumah Sakit Penerima Pasien

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