RUMAH SAKIT KHUSUS BEDAH BUDI KASIH

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Telp. (0233) 8665508 Fax. (0233) 8665509

SURAT KONTROL BEROBAT JALAN

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

No. CM : .................................................................................................................

Diagnosa : .................................................................................................................

Poliklinik : .................................................................................................................

Tanggal Masuk Rawat Inap : .................................................................................................................

Tujuan : .................................................................................................................

Surat keterangan ini berlaku untuk 1 (satu) kali kunjungan dengan diagnosa di atas.

Majalengka, …………………………20….
DPJP

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