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RUMAH SAKIT IBU DAN ANAK AISYIYAH

PEKAJANGAN PEKALONGAN
Jl. Raya Pekajangan No.610 Kec.Kedungwuni Kab.Pekalongan
Telp. (0285) 785909 Kode Pos : 51172
Email : rba610@gmail.com

Kepada Yth ;

Kepala Ruang :........................................

RSIA Aisyiyah Pekajangan

SURAT PERINTAH OPNAME

......./SPO/................./.....................

Mohon diopname

Nama : ......................................................................N0.Kartu BPJS :..............................................

Tgl.Lahir : ............................................................................................................................................

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

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

Diagnosa : ............................................................................................................................................

Terima kasih

Pekajangan,.....................................20.....

Dokter yang memerintahkan opname

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