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Pemeriksaan dan Konsultasi Kesehatan Gratis Pemeriksaan dan Konsultasi Kesehatan Gratis

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


Tempat & Tanggal lahir : .................................................................................... Tempat & Tanggal lahir : ....................................................................................
Usia : ............... tahun Usia : ............... tahun

Anamnesa : .................................................................................... Anamnesa : ....................................................................................


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Hasil Pemeriksaan : .................................................................................... Hasil Pemeriksaan : ....................................................................................


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Diagnosa sementara : .................................................................................... Diagnosa sementara : ....................................................................................

Terapi atau Terapi atau


Rekomendasi Dokter : .................................................................................... Rekomendasi Dokter : ....................................................................................
.................................................................................... ....................................................................................
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dr. dr.
Pemeriksaan dan Konsultasi Kesehatan Gratis Pemeriksaan dan Konsultasi Kesehatan Gratis

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


Tempat & Tanggal lahir : .................................................................................... Tempat & Tanggal lahir : ....................................................................................
Usia : ............... tahun Usia : ............... tahun

Anamnesa : .................................................................................... Anamnesa : ....................................................................................


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

Hasil Pemeriksaan : .................................................................................... Hasil Pemeriksaan : ....................................................................................


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

Diagnosa sementara : .................................................................................... Diagnosa sementara : ....................................................................................

Terapi atau Terapi atau


Rekomendasi Dokter : .................................................................................... Rekomendasi Dokter : ....................................................................................
.................................................................................... ....................................................................................
.................................................................................... ....................................................................................

dr. dr.

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