PEMERINTAH KABUPATEN PANDEGLANG

D I N A S K E S E H A T A N
PUSKESMAS BANGKONOL KECAMATAN KORONCOONG
Jalan Raya Rangkasbitung km. 4 Pandeglang

BUKTI PELAYANAN PNC

Telah dilakukan pelayanan terhadap:

Nama : ..................................................................................................................
Umur : ..................................................................................................................
No. Kartu : ..................................................................................................................
No. Handphone : ..................................................................................................................
Tanggal Pelayanan : ..................................................................................................................
Jenis Pelayanan : ..................................................................................................................
Bersama ini terlampir masing-masing:
1. Fotocopy Identitas Perserta BPJS Kesehatan dan KTP/KK.

Pandeglang, ....................................20...
Pelayanan tersebut telah diterima
Penderita/keluarga Petugas yang merawat

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