DEA
REKAM MEDIS
PASIEN RAWAT JALAN
NAMA :...…………………...……...................
BPJS PBI NO. KARTU BPJS :
NAMA KK :...…………………..……....................
LK/PR/UMUR :............................................................. BPJS NON PBI
AGAMA :...………………………….................. UMUM
PEKERJAAN :...……………………..................…… RIWAYAT ALLERGI :
ALAMAT :......………………………...............… LAINNYA
TELP./HP :...........................................................