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Kartu Indeks Utama Pasien

Jl. Jendral A.Yani No. 26 (KIUP)


Telp. 0751 – 21953

No. MR :

Nama :.........................................................................................................................

Tempat /Tanggal Lahir :.........................................................................................................................

Alamat :.........................................................................................................................

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Jenis kelamin : Laki-Laki Perempuan

Agama :........................................................................................................................

Pekerjaan :........................................................................................................................

No.Telp / HP :........................................................................................................................

Nama Ayah / Ibu :........................................................................................................................

Jenis Pembayaran : Pribadi BPJS Asuransi

No. Kartu :.........................................................................................................................

Kartu Indeks Utama Pasien


Jl. Jendral A.Yani No. 26 (KIUP)
Telp. 0751 – 21953
No. MR :

Nama :.........................................................................................................................

Tempat /Tanggal Lahir :.........................................................................................................................

Alamat :.........................................................................................................................

.........................................................................................................................

Jenis kelamin : Laki-Laki Perempuan

Agama :........................................................................................................................

Pekerjaan :........................................................................................................................

No.Telp / HP :........................................................................................................................

Nama Ayah / Ibu :........................................................................................................................

Jenis Pembayaran : Pribadi BPJS Asuransi

No. Kartu :.........................................................................................................................

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