No. Med.

REC :

DATA IDENTITAS PASIEN

Nama lengkap pasien sesuai kartu identitas : ..................................................................................

Nama Keluarga ( Ayah/Suami/Marga) : ..................................................................................

Alamat lengkap :Jl. ...............................................................................

...................................................................................

Kelurahan.........................Kecamatan.........................

Kota.............................................................................

No. Telepon / Handphone :...................................................................................

Tempat/ Tanggal Lahir : ..................................................................................

Jenis Kelamin : Laki-laki / Perempuan

Status Perkawinan : Sudah menikah / Belum menikah

Kewarganegaraan : Indonesia / Lain : ......................................................

Agama : Islam/ katolik / Kristen / Budha/ Hindu/...................

Pekerjaan : ...................................................................................

Data Wali Pasien :

Nama Lengkap : ...................................................................................

Hubungan dengan pasien : Suami/ Istri, Anak, Orang tua, Lain :........................

No. Handphone : ...................................................................................

Petugas Pendaftaran, Makassar, ................................

Tanda tangan dan Nama Jelas Tanda tangan Pasien/ Wali