RSIA SANTA ANNA

Jl. Hasanudin No. 27 Telukbetung _ Bandar Lampung

Telp. (0721) 482424 / E-mail: rsia_st.anna@yahoo.co.id

IDENTIFIKASI PASIEN RAWAT JALAN

Nama :
TTL :
No. RM :
No. NIK :

Tanggal Daftar : ______________________

Nama Pasien : _________________________________________________________________ L / P

Tanggal Lahir : _______________________________________________________________________

Alamat : _______________________________________________________________________

_______________________________________________________________________

No Telp : _______________________________________________________________________

Suku :_______________________________________________________________________

Warga Negara :_______________________________________________________________________

Pekerjaan :_______________________________________________________________________

Pendidikan : _______________________________________________________________________

Agama : _______________________________________________________________________

Golongan darah : _________________________________________________________________

No. Kartu Identitas : _______________________________________KTP/SIM/KITAS/PASSPORT*

Status Pernikahan : Kawin/Belum Kawin/Cerai/Duda/Janda/Lain-lain*________________________

Nama penanggung biaya : _______________________________________________________

Perusahaan / Suami / Isteri / Keluarga / Orangtua/BPJS/Asuransi*

Pekerjaan : ______________________________________________________

Petugas Pendaftaran : 1. Elisabeth Mega F

2. Lusiana Tri Rahayu

3. Maria Eka Intani Putri

4. Ayu Maudi Lestari

5. Sr. Paula, HK

6. Ellen Oktarina

RM 01A/DP.RI/05/2018Rev.1
*) Coret yang tidak perlu