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KARTU IBU

Lembar KIA – 3

PUSKESMAS : _________________________________________________________________________
NO. IBU : _________________________________________________________________________

NAMA LENGKAP : _________________________________________________________________________

NAMA SUAMI 3 : ________________________________________________________________________

TANGGAL LAHIR : _____________________________________ UMUR : _________________________________

ALAMAT DOMISILI : _____________________________________ RT/RW : _________________________________

DESA : _____________________________________ KEC. : _________________________________

KABUPATEN : _____________________________________ PROV : _________________________________

PENDIDIKAN : _____________________________________ AGAMA : _________________________________

PEKERJAAN : _____________________________________TGL REGISTER ____________________________

PEMERINTAH KABUPATEN CILACAP


UPTD PUSKESMAS BINANGUN
Alamat: Jl. A. Yani No. 15 Binangun Telp. 0282 – 5293429
E-mail: UPTDpuskesmasbinangun@gmail.com

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