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1. Nama : ............................ LK/PR 5. Nama : ............................

LK/PR
Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................

2. Nama : ............................ LK/PR 6. Nama : ............................ LK/PR


Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................

3. Nama : ............................ LK/PR 7. Nama : ............................ LK/PR


Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................

4. Nama : ............................ LK/PR 8. Nama : ............................ LK/PR


Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................
9. Nama : ............................ LK/PR 13. Nama : ............................ LK/PR
Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................

10. Nama : ............................ LK/PR 14. Nama : ............................ LK/PR


Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................

11. Nama : ............................ LK/PR 15. Nama : ............................ LK/PR


Umur : ..................th Umur : ..................th
MR : ............................ MR : ............................
Kel. Utama : ............................ Kel. Utama : ............................
Diagnosis : ............................ Diagnosis : ............................
K. Bedah : ............................ K. Bedah : ............................
Dorong ke : ............................ Dorong ke : ............................

12. Nama : ............................ LK/PR 16. Nama : ............................ LK/PR

Umur : ..................th Umur : ..................th

MR : ............................ MR : ............................

Kel. Utama : ............................ Kel. Utama : ............................

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

K. Bedah : ............................ K. Bedah : ............................

Dorong ke : ............................ Dorong ke : ............................

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