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Nama : ………………………………………………………

Tanggal Lahir : ………………………………………………………


Pertama HD/ Hari HD : ………………………………………………………
No. HP/ Alamat : ………………………………………………………
No. RM : ………………………………………………………
No. BPJS : ………………………………………………………
Gol. Darah : ………………………………………………………

- RS BHAYANGKARA TK III BALIKPAPAN –


- RS BHAYANGKARA TK III BALIKPAPAN –
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
Hari/ tanggal
Keluhan Diagnosis Terapi
HD ke-
Hasil Laboratorium
LFG Dokter Keterangan
Hb Leukosit Ur Cr
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