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