LEMBAR BUKTI PELAYANAN

RSU. WULAN WINDY

Nama pasien : ..................................................... Pemeriksaan dokter Rp. ..........................

Tanggal Lahir : ..................................................... Pemeriksaan penunjang :
Diagnosa : ..................................................... Laboratorium Rp. ..........................
......................................................................................... Radiologi Rp. ..........................
Therapy : ...................................................... EKG Rp. ..........................
......................................................................................... ................................ Rp. ..........................
......................................................................................... Obat-obatan Rp. ..........................
......................................................................................... Tindakan Lain Rp. ..........................

Medan, ..................................
Tanda tangan pasien Tanda tangan dokter

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

LEMBAR BUKTI PELAYANAN

RSU. WULAN WINDY

Nama pasien : ..................................................... Pemeriksaan dokter Rp. ..........................

Tanggal Lahir : ..................................................... Pemeriksaan penunjang :
Diagnosa : ..................................................... Laboratorium Rp. ..........................
......................................................................................... Radiologi Rp. ..........................
Therapy : ...................................................... EKG Rp. ..........................
......................................................................................... ................................ Rp. ..........................
......................................................................................... Obat-obatan Rp. ..........................
......................................................................................... Tindakan Lain Rp. ..........................

Medan, ..................................
Tanda tangan pasien Tanda tangan dokter

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