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DEPAN

No : ..........................................

Apoteker : Ninuk Nurhandika, S.Farm., Apt.


Tempeh-Lumajang. Telp. 081252169890
No. .....................................
Tanggal : ..............................

APOTEK HAKIM FARMA


Jl. Wachid Hasyim Ds.Pandanwangi-
Terima dari : Terima dari : ...................................................................................................................................................

SIPA : 35.08/2018/2010.1
SIA : 44/SIA-LMJ/V/2018
....................................................
Terbilang :
....................................................
Jumlah :
Untuk pembayaran resep dokter : .............................................................. Tgl ................................
....................................................
.................................................... Pro : ........................................................................................................................... No .................................
Pembayaran R/ dokter :
Lumajang, .........................................
....................................................
No : ........................................... Jumlah Rp.
Penerima :
....................................................
BELAKANG

APOTEK HAKIM FARMA


Jl. Wachid Hasyim Ds.Pandanwangi-
Tempeh-Lumajang. Telp. 081252169890
Apoteker : Ninuk Nurhandika, S.Farm., Apt.
SIPA : 35.08/2018/2010.1
SIA : 44/SIA-LMJ/V/2018

Dokter : ......................................................................................
Lumajang, ..................................

R/

Pro : ............................................................................................
Umur : .........................................................................................

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