FORM./RM.

DOC RUMAH SAKIT UTAMA

HUSADA
Jalan Manggar 134 Tegalsari – Ambulu
Telp. (0336) – 881186, 881187

CAP TELAPAK KAKI BAYI No. RM

RUANG KELAS :

Nama Ibu Bayi : ..................................................................

Alamat : ..................................................................

Tanggal Lahir Bayi : ..................................................................

Jam Lahir Bayi : ..................................................................

Berat Badan Bayi : ..................................................................

Panjang Bayi : ..................................................................

Jenis Kelamin Bayi : ..................................................................

Apgar Score : ..................................................................

CAP TELAPAK JARI KAKI BAYI ( Kanan dan Kiri )

KAKI KIRI KAKI KANAN

Ambulu, ...............................................

Dokter Penolong

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