RUMAH SAKIT UIN SYAHID RUMAH SAKIT UIN SYAHID RUMAH SAKIT UIN SYAHID RUMAH SAKIT UIN SYAHID
Apoteker : ________________________ Apoteker : ________________________ Apoteker : ________________________ Apoteker : ________________________
SIPA : 0252/2.34/31.71.04/-1.779.3/2017 SIPA : 0252/2.34/31.71.04/-1.779.3/2017 SIPA : 0252/2.34/31.71.04/-1.779.3/2017 SIPA : 0252/2.34/31.71.04/-1.779.3/2017
Tgl : _____________________________ Tgl : _____________________________ Tgl : _____________________________ Tgl : _____________________________
Nama Pasien : ____________________________ Nama Pasien : ____________________________ Nama Pasien : ____________________________ Nama Pasien : ____________________________
No. Resep : _____________________________ No. Resep : _____________________________ No. Resep : _____________________________ No. Resep : _____________________________
Nama Obat : ____________________________ Nama Obat : ____________________________ Nama Obat : ____________________________ Nama Obat : ____________________________
R/ R/
R/ R/