Img042 PDF
Img042 PDF
Nama .. ····················································-
Umur : ..�... tahun ...........................�. Jenls kelamin: Lak� laki(Perempua])
Alamat : ..?!f.:.....�.�....Plt!J!�..,.:.....�..........................................................
Perlu istiralmt selama J.(.:f�e.rhan kattna sakit-
. / / tj sampai dengan. tanggal
Mula, tanggal ........................... / /�
_ _ ....................... .