Nama............................MR............... Nama............................MR...............
Ruangan :…………………................ Ruangan :…………………................
Paket berisi.............................injeksi Paket berisi.............................injeksi
Tgl & waktu penyiapan...................... Tgl & waktu penyiapan......................
Nama............................MR............... Nama............................MR...............
Ruangan :…………………................ Ruangan :…………………................
Paket berisi.............................injeksi Paket berisi.............................injeksi
Tgl & waktu penyiapan...................... Tgl & waktu penyiapan......................
Nama............................MR............... Nama............................MR...............
Ruangan :…………………................ Ruangan :…………………................
Paket berisi.............................injeksi Paket berisi.............................injeksi
Tgl & waktu penyiapan...................... Tgl & waktu penyiapan......................
Nama............................MR............... Nama............................MR...............
Ruangan :…………………................ Ruangan :…………………................
Paket berisi.............................injeksi Paket berisi.............................injeksi
Tgl & waktu penyiapan...................... Tgl & waktu penyiapan......................
Nama............................MR............... Nama............................MR...............
Ruangan :…………………................ Ruangan :…………………................
Paket berisi.............................injeksi Paket berisi.............................injeksi
Tgl & waktu penyiapan...................... Tgl & waktu penyiapan......................