PEMERINTAH DAERAH KABUPATEN TASIKMALAYA

DINAS KESEHATAN
UPT PUSKESMAS CIPATUJAH
Jalan Raya Cipatujah Nomor : 123 Telepon : (0265) 7580480
Website : puskesmascipatujah@blogspot.co.id e-mail : pkmcipatujah@gmail.com
Cipatujah – 46189

No. RM :

SURAT IZIN MENINGGALKAN PUSKESMAS

NO : ........................................................................

Nama : ............................................................. Umur : ......... Jenis Kelamin : L / P

Alamat : .............................................................................................................................
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Diagnosa Akhir : .............................................................................................................................
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Pemeriksaan : .............................................................................................................................
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Keterangan : Sembuh / Belum Sembuh / Perbaikan
Nasehat : .............................................................................................................................
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PERHATIAN : SETIAP AKAN BEROBAT KARTU INI HARUS DIBAWA

Cipatujah, .............................................. 20 ....

Dokter Pemeriksa

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