Jalan Raya Dasan Lekong - Masbagik, Kode Pos :83652, telp.: (0376)23861
Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Tanggal Keluar : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................
( ......................................................... )
Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Tanggal Keluar : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................
( ......................................................... )