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PEMERINTAH KOTA TANGERANG SELATAN

DINAS KESEHATAN Nomor Rekam Medik

UPT PUSKESMAS PONDOK BENDA


Jalan Benda Barat XIV Pamulang Permai 2
Kelurahan Pondok Benda, Kec. Pamulang – Tangerang Selatan,Telp: 021-74639677

SURAT KETERANGAN KONTROL

Dokter UPT Puskesmas Pondok Benda, menerangkan bahwa :


Nama : ...................................................L/P Umur : ..........................Hari / Bulan / Tahun
Alamat : ........................................................................................................................................
Mulai dirawat : ........................................................................................................................................
Diijinkan pulang : .................................................................................... Sembuh / belum sembuh / APS
Diagnosa : ........................................................................................................................................
Therapi : ........................................................................................................................................
Nasehat : ........................................................................................................................................
Kontrol Tgl : ................... Jam : .................. Di : .................................
Dengan Membawa : □ Surat Kontrol □ Buku KIA

Pondok Benda ,.........................................20...


Dokter/ Bidan/ Perawat

(........................................)

PEMERINTAH KOTA TANGERANG SELATAN


DINAS KESEHATAN Nomor Rekam Medik

UPT PUSKESMAS PONDOK BENDA


Jalan Benda Barat XIV Pamulang Permai 2
Kelurahan Pondok Benda, Kec. Pamulang – Tangerang Selatan,Telp: 021-74639677

SURAT KETERANGAN KONTROL

Dokter UPT Puskesmas Pondok Benda, menerangkan bahwa :


Nama : ...................................................L/P Umur : ..........................Hari / Bulan / Tahun
Alamat : ........................................................................................................................................
Mulai dirawat : ........................................................................................................................................
Diijinkan pulang : .................................................................................... Sembuh / belum sembuh / APS
Diagnosa : ........................................................................................................................................
Therapi : ........................................................................................................................................
Nasehat : ........................................................................................................................................
Kontrol Tgl : ................... Jam : .................. Di : .................................
Dengan Membawa : □ Surat Kontrol □ Buku KIA

Pondok Benda ,.........................................20...


Dokter/ Bidan/ Perawat

(........................................)

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