DINAS KESEHATAN
PUSKESMAS DORO 1
Jl. A. Yani – Doro Telp (0285) 448783 Kab.PekalonganKodePos 51191
Email : puskdorone@gmail.com
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Jenis Kelamin : L/P Umur : ................................................................
Pekerjaan : .................................................................................................................
Alamat : .................................................................................................................
Keadaan Klinis : .................................................................................................................
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Doro, ………………………
Mengetahui,
Kepala Puskesmas Doro Dokter yang memeriksa
Kabupaten Pekalongan