PFM/MR/UMU/22

PEMERINTAH KABUPATEN JEMBER

DINAS KESEHATAN
UPT PUSKESMAS MAYANG
Jl. Pahlawan no. 32 Kecamatan Mayang telp. 0331-591918
JEMBER 68182

LEMBAR KONTROL PASIEN

Nama penderita :...........................................................................

No. Register :..........................................................................

Umur :...........................................................................

Nama KK :...........................................................................

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

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

Status Pasien :...........................................................................

Diagnosis :...........................................................................

Therapi :...........................................................................

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Petugas

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1. Perlu kontrol kembali :..........................................

2. Perlu konsultasi ahli lain :..........................................
3. Konsultasi selesai :..........................................

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