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PUSKESMAS DASAN LEKONG

Jalan Raya Dasan Lekong - Masbagik, Kode Pos :83652, telp.: (0376)23861

SURAT KONTROL PASIEN

Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Tanggal Keluar : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................

Dasan Lekong, .................................................


Petugas

( ......................................................... )

PUSKESMAS DASAN LEKONG


Jalan Raya Dasan Lekong - Masbagik, Kode Pos :83652, telp.: (0376)23861

SURAT KONTROL PASIEN

Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Tanggal Keluar : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................

Dasan Lekong, .................................................


Petugas

( ......................................................... )

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