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RESUME MEDIS RAWAT JALAN

No. Rekam Medis :

Nama Pasien : ................................................................................................................................................................


Tanggal Lahir : ................................................................................................................................................................
Tanggal Pemeriksaan : ................................................................................................................................................................
Klinik / Dokter : dr. Masjelita Sp.Kj
Lembar untuk diisi dokter
Anamnesa : ................................................................................................................................................................
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Diagnosa : ..................................................................................................................................... ...........................
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Terapi : ................................................................................................................................................................
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Anjuran : ................................................................................................................................................................
Dengan ini saya selaku pasien / tertanggung, mengizinkan dr. Masjelita Sp.Kj untuk memberikan keterangan lengkap mengenai
keadaan penyakit / data medis kepada pihak ketiga yang ditunjuk secara sah.

( ) ( )
Pasien Pasien / Tertanggung Dokter
Arsip
Perusahaan

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