Blanko Perincian Rawat Jalan

PERINCIAN RAWAT JALAN / POLY UMUM PERINCIAN RAWAT JALAN / POLY UMUM
TGL : ........................................ UMUR : ............................................... TGL : ........................................ UMUR : ...............................................
NAMA : ........................................ ALAMAT : ............................................... NAMA : ........................................ ALAMAT : ...............................................
1. TINDAKAN MEDIK NON MEDIK OPERATIF RINGAN = Rp. ............................... 1. TINDAKAN MEDIK NON MEDIK OPERATIF RINGAN = Rp. ...............................
2. TINDAKAN MEDIK NON OPERATIF SEDANG = Rp. ............................... 2. TINDAKAN MEDIK NON OPERATIF SEDANG = Rp. ...............................
3. TINDAKAN MEDIK NON OPERATIF BERAT = Rp. ............................... 3. TINDAKAN MEDIK NON OPERATIF BERAT = Rp. ...............................
4. APOTIK + JASA FARMASI = Rp. ............................... 4. APOTIK + JASA FARMASI = Rp. ...............................
5. EKG / USG / RONGENT = Rp. ............................... 5. EKG / USG / RONGENT = Rp. ...............................
6. VISUM = Rp. ............................... 6. VISUM = Rp. ...............................
7. AMBULANCE = Rp. ............................... 7. AMBULANCE = Rp. ...............................
8. LABORATORIUM = Rp. ............................... 8. LABORATORIUM = Rp. ...............................
9. GDA = Rp. ............................... 9. GDA = Rp. ...............................
PERINCIAN RAWAT JALAN / POLY UMUM PERINCIAN RAWAT JALAN / POLY UMUM
TGL : ........................................ UMUR : ............................................... TGL : ........................................ UMUR : ...............................................
NAMA : ........................................ ALAMAT : ............................................... NAMA : ........................................ ALAMAT : ...............................................
1. TINDAKAN MEDIK NON MEDIK OPERATIF RINGAN = Rp. ............................... 1. TINDAKAN MEDIK NON MEDIK OPERATIF RINGAN = Rp. ...............................
2. TINDAKAN MEDIK NON OPERATIF SEDANG = Rp. ............................... 2. TINDAKAN MEDIK NON OPERATIF SEDANG = Rp. ...............................
3. TINDAKAN MEDIK NON OPERATIF BERAT = Rp. ............................... 3. TINDAKAN MEDIK NON OPERATIF BERAT = Rp. ...............................
4. APOTIK + JASA FARMASI = Rp. ............................... 4. APOTIK + JASA FARMASI = Rp. ...............................
5. EKG / USG / RONGENT = Rp. ............................... 5. EKG / USG / RONGENT = Rp. ...............................
6. VISUM = Rp. ............................... 6. VISUM = Rp. ...............................
7. AMBULANCE = Rp. ............................... 7. AMBULANCE = Rp. ...............................
8. LABORATORIUM = Rp. ............................... 8. LABORATORIUM = Rp. ...............................
9. GDA = Rp. ............................... 9. GDA = Rp. ...............................

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Blanko Perincian Rawat Jalan

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PERINCIAN RAWAT JALAN / POLY UMUM PERINCIAN RAWAT JALAN / POLY UMUM

TGL : ........................................ UMUR : ............................................... TGL : ........................................ UMUR : ...............................................

NAMA : ........................................ ALAMAT : ............................................... NAMA : ........................................ ALAMAT : ...............................................

6. VISUM = Rp. ............................... 6. VISUM = Rp. ...............................

7. AMBULANCE = Rp. ............................... 7. AMBULANCE = Rp. ...............................

8. LABORATORIUM = Rp. ............................... 8. LABORATORIUM = Rp. ...............................

9. GDA = Rp. ............................... 9. GDA = Rp. ...............................

TGL : ........................................ UMUR : ............................................... TGL : ........................................ UMUR : ...............................................

NAMA : ........................................ ALAMAT : ............................................... NAMA : ........................................ ALAMAT : ...............................................

6. VISUM = Rp. ............................... 6. VISUM = Rp. ...............................

7. AMBULANCE = Rp. ............................... 7. AMBULANCE = Rp. ...............................

8. LABORATORIUM = Rp. ............................... 8. LABORATORIUM = Rp. ...............................

9. GDA = Rp. ............................... 9. GDA = Rp. ...............................

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