Anda di halaman 1dari 1

PUSKESMAS/KLINIK/DPP

Praktek dr.Dwi Yanty

FORMULIR RESEP KACAMATA

Visus : 0D = .......... OS = ..........

Vitrum Spher Vitrum Cylinder Axis Pupil Distance


Oculi Dextra
Oculi Sinistra
Add

Nama : ..............................

Umur : ..............................

No. JKN : ..............................

Pemeriksa, Lubuklinggau, 2021

(........................................ ) (dr. Dwi Yanty )

PUSKESMAS/KLINIK/DPP
Praktek dr.Dwi Yanty

FORMULIR RESEP KACAMATA

Visus : 0D = .......... OS = ..........

Vitrum Spher Vitrum Cylinder Axis Pupil Distance


Oculi Dextra
Oculi Sinistra
Add

Nama : ..............................

Umur : ..............................

No. JKN : ..............................

Pemeriksa, Lubuklinggau, 2021

(........................................ ) (dr. Dwi Yanty )

Anda mungkin juga menyukai