Anda di halaman 1dari 1

Barimba, .................................... Barimba, .................................... Barimba, ....................................

Dokter/Perawat/Bidan : ........................................................................... Dokter/Perawat/Bidan : ……………………………………………….......................... Dokter/Perawat/Bidan : ……………………………………………….........................


SIP/SIK : ………………………………………………….…………........... SIP/SIK : ……………………………………………………………….......... SIP/SIK : ……………………………………………………………...........

R/ R/ R/

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


Umur : ................................... Umur : ................................... Umur : ...................................
Alamat : ................................................................................. Alamat : ................................................................................. Alamat : .................................................................................
No. ID : .........................................(JKN/JAMKESDA/UMUM) No. ID : .........................................(JKN/JAMKESDA/UMUM) No. ID : .........................................(JKN/JAMKESDA/UMUM)

Anda mungkin juga menyukai