DINAS KESEHATAN
PUSKESMAS TANAH ABANG
Jl. Puskesmas Dusun I Desa Tanah Abang Kec.Batanghari Leko
1. Nama : .........................................................................................................
2. Nama Suami : .........................................................................................................
3. Nomor Kartu BPJS : .........................................................................................................
4. Tanggal Pelayanan : .........................................................................................................
5. Diagnosa : .........................................................................................................
6. Alamat : .........................................................................................................
: .........................................................................................................
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Penerima Pelayanan Kesehatan Yang Memberi Pelayanan Kesehatan
( ....................................................... ) ( ....................................................... )