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RUMAH SAKIT

SARI ASIH RESUME MEDIS RAWAT JALAN

No. Rekam Medis :

Nama Pasien : ................................................................................................................................................................


Tanggal Lahir : ................................................................................................................................................................
Tanggal Pemeriksaan : ................................................................................................................................................................
Klinik / Dokter : ................................................................................................................................................................
Lembar untuk diisi dokter
Anamnesa : ................................................................................................................................................................
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Diagnosa : ................................................................................................................................................................
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Terapi : ................................................................................................................................................................
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Anjuran : ................................................................................................................................................................
Dengan ini saya selaku pasien / tertanggung, mengizinkan RS. Sari Asih Karawaci untuk memberikan keterangan lengkap
mengenai keadaan penyakit / data medis kepada pihak ketiga yang ditunjuk secara sah.

( ____________________ ) ( ____________________ )
Pasien Pasien / Tertanggung Dokter
Arsip
Perusahaan

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