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PEMERINTAH PROVINSI SUMATERA SELATAN
DINAS KESEHATAN
RUMAH SAKIT KHUSUS MATA
PROVINSI SUMATERA SELATAN
JL KOH H BURLIAN KM 6 PALEMBANG
FORMULIR BUKTI TINDAKAN
NAMA PASIEN :....................................................................................................................................................
NO KARTU :....................................................................................................................................................
NO RUJUKAN :....................................................................................................................................................
ASAL RUJUKAN :....................................................................................................................................................
KEPESERTAAAN : P / I / S / A
JENIS KELAMIN : L / P
DIAGNOSA :....................................................................................................................................................
TINDAKAN :....................................................................................................................................................
……..…………………………………………………..
PASEIN DOKTER YANG MEMERIKSA
1. (………………………)
2. (………………………)
(………………………) 3. (………………………)
PEMERINTAH PROVINSI SUMATERA SELATAN

DINAS KESEHATAN
RUMAH SAKIT KHUSUS MATA
PROVINSI SUMATERA SELATAN
JL KOH H BURLIAN KM 6 PALEMBANG
FORMULIR BUKTI TINDAKAN
NAMA PASIEN :....................................................................................................................................................
NO KARTU :....................................................................................................................................................
NO RUJUKAN :....................................................................................................................................................
ASAL RUJUKAN :....................................................................................................................................................
KEPESERTAAAN : P / I / S / A
JENIS KELAMIN : L / P
DIAGNOSA :....................................................................................................................................................
TINDAKAN :....................................................................................................................................................
……..…………………………………………………..
PASEIN DOKTER YANG MEMERIKSA
1. (………………………)
2. (………………………)
(……..…………….……………) 3. (………………………)

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PEMERINTAH PROVINSI SUMATERA SELATAN

FORMULIR BUKTI TINDAKAN

NAMA PASIEN :....................................................................................................................................................

ASAL RUJUKAN :....................................................................................................................................................

PEMERINTAH PROVINSI SUMATERA SELATAN

FORMULIR BUKTI TINDAKAN

NAMA PASIEN :....................................................................................................................................................

ASAL RUJUKAN :....................................................................................................................................................

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