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PEMERINTAH KABUPATEN SIGI

DINAS KESEHATAN
PUSKESMAS GIMPU
KECAMATAN KULAWI SELATAN
Jln. Poros Palu Gimpu Desa Lawua Kec.Kulawi Selatan Kode Pos 94363

UNTUK PENINGKATAN DAN PERBAIKAN LAYANAN YANG


KAMI BERIKAN SILAHKAN MENYAMPAIKAN
MASUKAN/KOMENTAR/SARAN ATAUPUN PERTANYAAN
DENGAN MENGISI FORMULIR BERIKUT INI:

NAMA : ...................................................................................
NOMOR TELPON/HP : ....................................................................................
ALAMAT : ...............................................................................
TOPIK : ...................................................................................
ISI SARAN/PERTANYAAN :
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TANGGAL,.................................

TANDA TANGAN
PEMERINTAH KABUPATEN SIGI
DINAS KESEHATAN
PUSKESMAS GIMPU
KECAMATAN KULAWI SELATAN
Jln. Poros Palu Gimpu Desa Lawua Kec.Kulawi Selatan Kode Pos 94363

UNTUK PENINGKATAN DAN PERBAIKAN LAYANAN YANG KAMI


BERIKAN SILAHKAN MENYAMPAIKAN MASUKAN/KOMENTAR/SARAN
ATAUPUN PERTANYAAN DENGAN MENGISI FORMULIR BERIKUT INI:

NAMA : ...............................................................................................
NOMOR TELPON/HP : ...............................................................................................
ALAMAT : ...............................................................................................
TOPIK : ...............................................................................................
ISI SARAN/PERTANYAAN :

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TANGGAL,.................................

TANDA TANGAN
PEMERINTAH KABUPATEN SIGI
DINAS KESEHATAN
PUSKESMAS GIMPU
KECAMATAN KULAWI SELATAN
Jln. Poros Palu Gimpu Desa Lawua Kec.Kulawi Selatan Kode Pos 94363

UNTUK PENINGKATAN DAN PERBAIKAN LAYANAN YANG KAMI


BERIKAN SILAHKAN MENYAMPAIKAN MASUKAN/KOMENTAR/SARAN
ATAUPUN PERTANYAAN DENGAN MENGISI FORMULIR BERIKUT INI:

NAMA : ...............................................................................................
NOMOR TELPON/HP : ...............................................................................................
ALAMAT : ...............................................................................................
TOPIK : ...............................................................................................
ISI SARAN/PERTANYAAN :

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

TANGGAL,.................................

TANDA TANGAN
PEMERINTAH KABUPATEN SIGI
DINAS KESEHATAN
PUSKESMAS GIMPU
KECAMATAN KULAWI SELATAN
Jln. Poros Palu Gimpu Desa Lawua Kec.Kulawi Selatan Kode Pos 94363

UNTUK PENINGKATAN DAN PERBAIKAN LAYANAN YANG KAMI


BERIKAN SILAHKAN MENYAMPAIKAN MASUKAN/KOMENTAR/SARAN
ATAUPUN PERTANYAAN DENGAN MENGISI FORMULIR BERIKUT INI:

NAMA : ...............................................................................................
NOMOR TELPON/HP : ...............................................................................................
ALAMAT : ...............................................................................................
TOPIK : ...............................................................................................
ISI SARAN/PERTANYAAN :

.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................
.........................................................................................................................................

TANGGAL,.................................

TANDA TANGAN