RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , 18 Desember 2019
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1.75 75 -1 90 62
longin
quitat
Pro
Propin
quitat

Pro Idawani Jailani

Umur 38 Tahun Banda Aceh , 08 Januari 2020
Nomor Telepon/Hp 0813 7739 6195
Nomor JKN 0001 8700 4447 8
Diagnosa Astigmatisme + Miopia
No Kunjungan Pcare 0101 0402 0120 P000 400

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA
 FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1.5 -2
longin
quitat
Pro
Propin
quitat

Pro
Umur : 15 tahun Banda Aceh , 19 Desember 2019
Nomor Telepon/Hp : 0813 6006 8096
Nomor JKN : 0000228670841
Diagnosa : Myopia
No Kunjungan Pcare : 010104021219P001081

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

 90° 90° R/KACAMATA Single Focus
Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro PL 0.75
longin
quitat
Pro
Propin
quitat

Pro : M.Ardian
Umur : 52 tahun Banda Aceh , 20 Desember 2019
Nomor Telepon/Hp 0812 6906 885
Nomor JKN : 0000001089369
Diagnosa : Hypermetropia
No Kunjungan Pcare : 010104021219P001209

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
 D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0.25 180 -0.25 180
longin
quitat
Pro
Propin
quitat

Pro : Dalila Nova

Umur : 18 tahun Banda Aceh , 20 Desember 2019
Nomor Telepon/Hp : 0812 2394 5704
Nomor JKN : 0000194362716
Diagnosa : Astigmatisma
No Kunjungan Pcare : 010104021219P001237

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S
 O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0.5 -0.5 -0.25 66
longin
quitat
Pro +1.75 +1.75
Propin
quitat

Pro : JUSTIAWATI
Umur : 47 tahun Banda Aceh , 20 Desember 2019
Nomor Telepon/Hp : 0812 2394 5704
Nomor JKN : 0000001088234
Diagnosa : Myopia + Astigmatisme
No Kunjungan Pcare : 010104021219P000935

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
 Pro -0.75
longin
quitat
Pro
Propin
quitat

Pro : MUHAMMAD RAIYAN

Umur : 21 tahun Banda Aceh , 21 Desember 201
Nomor Telepon/Hp : 0812 6906 885
Nomor JKN : 0000001089371
Diagnosa : Myopia
No Kunjungan Pcare : 010104021219P001289

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1 -1.25 -0.5 5
longin
quitat
 Pro
Propin
quitat

Add +2.00

Pro Rosmalinda
Umur 50 tahun Banda Aceh , 3 Januari 2020
Nomor Telepon/Hp 0813 6046 3756
Nomor JKN 1393198
Diagnosa Myopia + Astigmatisme
No Kunjungan Pcare 010104020120P000133

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -250 -200 -25 25 62
longin
quitat
Pro
Propin
quitat
Pro Ade Rizka Y
Umur 22 Tahun Banda Aceh , 14 Januari 2020
Nomor Telepon/Hp 0821 6506 7707
Nomor JKN ,0001116043604
Diagnosa Astigmatisme + Miopia
No Kunjungan Pcare 010104020120P000729

(dr Sri Wahyuni)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0,75 +1,25 64
longin
quitat
Pro
Propin +2,25 +2,25 62
quitat
Pro MUSLIM RAFZIRSYAH
Umur 49 Tahun Banda Aceh , 14 Januari 2020
Nomor Telepon/Hp
Nomor JKN ,0000001092137
Diagnosa Hipermetrop + Presbiopia
No Kunjungan Pcare 010104020120P000751

(dr Sri Wahyuni)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1,00 -1,00 58
longin
quitat
Pro
Propin
quitat

Pro VAZIRA WILDA RAFUSA

Umur 17 Tahun Banda Aceh , 14 Januari 2020
Nomor Telepon/Hp
Nomor JKN 0000001092148
Diagnosa Myopia
No Kunjungan Pcare 010104020120P000715

(dr Sri Wahyuni)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -2.25 -2.5 62
longin
quitat
Pro
Propin
quitat

Pro : Mustika Yulia

Umur : 18 tahun Banda Aceh , 18 Desember 2019
Nomor Telepon/Hp : 0821 7489 6959
Nomor JKN : 0001275977992
Diagnosa : Myopia
No Kunjungan Pcare : 010104021219P000870

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA
 FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0,50 +0,50
longin
quitat
Pro
Propin
quitat
Add +2,50

Pro :MARIAH
Umur : 55 Tahun Banda Aceh , 16 Januari 2020
Nomor Telepon/Hp :
Nomor JKN : 0000229053486
Diagnosa : Hypermetrop + Presbiopia
No Kunjungan Pcare :010104020120P000904

(dr Sri Wahyuni)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

 90° 90° R/KACAMATA Single Focus
Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,50 -0,75 150 -3,25 -1,75 95
longin
quitat
Pro
Propin
quitat
Add +3,00

Pro : Khairiah
Umur : 72 Tahun Banda Aceh , 17 Januari 2020
Nomor Telepon/Hp :
Nomor JKN :0001813597738
Diagnosa Myopia + Astegmatisme + Presbiopia
No Kunjungan Pcare :010104020120P000944

(dr Sri Wahyuni)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
 D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1.25 -0.5 145 -1 0.5 40
longin
quitat
Pro
Propin
quitat
Add

Pro : Maulana Yushar

Umur : 27 Tahun Banda Aceh ,20 Januari 2020
Nomor Telepon/Hp :
Nomor JKN : 0001 1110 7035 1
Diagnosa :myiopia, astigmatisma,
No Kunjungan Pcare :0101 0402 0120 P001 127

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S
 O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro 1.25 1.75
longin
quitat
Pro
Propin
quitat
Add

Pro :MILA SARTIKA

Umur : 29 Tahun Banda Aceh , 30 Januari 2020
Nomor Telepon/Hp : '0852 6024 3744
Nomor JKN :'0001 7753 8488 6
Diagnosa : Myopia
No Kunjungan Pcare :010104020120P001661

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
 Pro -0,75 -1,25 180 -0,75 1,00 180
longin
quitat
Pro
Propin
quitat

Pro : MUHAMMAD RIDWAN

Umur : 30 tahun Banda Aceh , 5 Februari 2020
Nomor Telepon/Hp 0812 6368 8553
Nomor JKN : 0002228166178
Diagnosa : Myopia + Astigmatisme
No Kunjungan Pcare : 010104020220P000144

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -3,00 -2,50
longin
quitat
 Pro
Propin
quitat

Pro : MUTIA KASMITA

Umur : 20 tahun Banda Aceh , 5 Desember 2019
Nomor Telepon/Hp :
Nomor JKN : 0001827892001
Diagnosa : Myopia
No Kunjungan Pcare : 010104020220P000225

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0,75
longin
quitat
Pro
Propin
quitat
 Add +1,25

Pro : KASMIDAR AR
Umur : tahun Banda Aceh , Desember 2019
Nomor Telepon/Hp :
Nomor JKN : 0001613672559
Diagnosa Hypermetropia + Presbiopia
No Kunjungan Pcare : 010104020220P000258

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.5
longin
quitat
Pro
Propin +1.75 +1.75
quitat
Pro : Darsila
Umur : 47 tahun Banda Aceh , 12 Februari 2020
Nomor Telepon/Hp : 0823 6872 2494
Nomor JKN : 0001 1191 4396 8
Diagnosa : Presbiopia + Hipermetropia
No Kunjungan Pcare : 0101 0402 0220 P000 550

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1,25 -1,00 110 -2,25 0,25 55 59
longin
quitat
Pro
Propin
quitat

Pro : ANNISA FARACH DHIBA

Umur : tahun Banda Aceh , 13 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0000001071753
Diagnosa : Myopia + Astigmatisme
No Kunjungan Pcare : 010104020220P000684

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,75 '-0,75 95 1,50 '-0,75 80 61
longin
quitat
Pro
Propin
quitat

Pro : ZAHRATUL FAHNI

Umur : tahun Banda Aceh , 18 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0001078564678
Diagnosa : Myopia + Astigmatisme
No Kunjungan Pcare : 010104020220P000820

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,25 85 0,25 95 66
longin
quitat
Pro
Propin
quitat
Add +1,25 +1,25

Pro : INDRA VAHLEVIE

Umur : 44 tahun Banda Aceh , 19 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0001803276156
Diagnosa : Astigmatisme
No Kunjungan Pcare : 010104020220P000858

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -4,00 -0,75 180 -4,00 -0,75 180
longin
quitat
Pro
Propin
quitat

Pro : FITRI YANI

Umur : 31 tahun Banda Aceh , 20 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0001790173282
Diagnosa : Myopia + Astigmatisme
No Kunjungan Pcare : 010104020220P000935

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +2,00 "+2,00
longin
quitat
Pro
Propin
quitat
add +2,75 +2,75

Pro : T USMAN HAMZAH

Umur : 63 tahun Banda Aceh , 20 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0000001112894
Diagnosa : Hipermetrop + Presbiopia
No Kunjungan Pcare : 010104020220P000957

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,25 -0,50 170 0,25 0,50 180
longin
quitat
Pro
Propin
quitat

Pro : IKRAMATURRABI'AH
Umur : 25 tahun Banda Aceh , 20 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0000976507964
Diagnosa Myopia + Astigmatisme
No Kunjungan Pcare : 010104020220P000951

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat

Pro : NURSHAFITRI
Umur : 22 tahun Banda Aceh , 20 Februari 2020
Nomor Telepon/Hp :
Nomor JKN : 0000001384547
Diagnosa : Myopia
No Kunjungan Pcare : 010104020220P000956

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +1,00 +1,00
longin
quitat
Pro
Propin
quitat
add +2,00 +2,00

Pro : FARAH HIJRIANI

Umur : 19 tahun Banda Aceh , 05 Maret 2020
Nomor Telepon/Hp :
Nomor JKN : 0002234386989
Diagnosa : Myopia
No Kunjungan Pcare : 010104020320P000271

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1,00 180
longin
quitat
Pro
Propin
quitat
add +1,75

Pro : SUMIATI
Umur : 48 tahun Banda Aceh , 5 Maret 2020
Nomor Telepon/Hp :
Nomor JKN :001798704854
Diagnosa :Astigmatisme
No Kunjungan Pcare :010104020320P000202

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,75 -0,50 65
longin
quitat
Pro
Propin
quitat
Add -1,25 -1,25

Pro : SALAMURA
Umur : 42 tahun Banda Aceh , 7 Maret 2020
Nomor Telepon/Hp :
Nomor JKN : 0000001283624
Diagnosa : Myopia + Presbiopia
No Kunjungan Pcare : 010104020320P000408

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,25 65 56
longin
quitat
Pro
Propin
quitat
Add +1,25 +1,25

Pro : DAHRIANI
Umur : 42 tahun Banda Aceh , 7 Maret 2020
Nomor Telepon/Hp :
Nomor JKN : 0000001283613
Diagnosa : Astigmatisme + Presbiopia
No Kunjungan Pcare : 010104020320P000407

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -2,00 -2,00
longin
quitat
Pro
Propin
quitat
Add +3,00

Pro : Rosmiati
Umur : 61 tahun Banda Aceh , 16 Maret 2020
Nomor Telepon/Hp :-
Nomor JKN : 0000168899545
Diagnosa : Myopia + Presbiopia
No Kunjungan Pcare : 01010420320P000845

(dr. Maisya Zahra)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -3,00 110 -3,50 80
longin
quitat
Pro
Propin
quitat
Add

Pro : MUNA ROSITA

Umur : tahun Banda Aceh , 20 Maret 2020
Nomor Telepon/Hp :
Nomor JKN : 0001303584221
Diagnosa : Astigmatisme
No Kunjungan Pcare : 010104020320P001146

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Maret 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

1
2
3
4
5
6
7
8
9
10
11
12
13
14
 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50
longin
quitat
Pro
Propin
quitat
Add +1.00 +1.00

Pro : Saudah
Umur : 38 tahun Banda Aceh , 27 April 2020
Nomor Telepon/Hp : 0821 6543 2664
Nomor JKN : 0000 2274 4005 35
Diagnosa : Hipermetropia
No Kunjungan Pcare : 01010420P000724

(dr Sri Wahuni)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50 +0.50
longin
quitat
Pro
Propin
quitat
Add +3.00

Pro : ABDULLAH M JAM

Umur : 61 tahun Banda Aceh , 30 April 2020
Nomor Telepon/Hp :-
Nomor JKN : 0000001354004
Diagnosa : Hipermetropia
No Kunjungan Pcare : 010104020420P000823

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50
longin
quitat
Pro
Propin
quitat
Add +1.50

Pro ARTUTI ARMAN

Umur 46 TAHUN 30 Desember 2020
Nomor Telepon/Hp
Nomor JKN 2077502951
Diagnosa HIPERMETROPIA,PRESBIOPIA
No Kunjungan Pcare 010104021220P00980

(dr sri wahyuni)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50 +0.50 63
longin
quitat
Pro
Propin
quitat
Add +1.75 +1.75

Pro : armia
Umur : 46 tahun Banda Aceh , 23 November 2020
Nomor Telepon/Hp : 0853 6030 5765
Nomor JKN : 0001 4760 1518 6
Diagnosa : Hipermetropia
No Kunjungan Pcare : 010104021120P000880

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50 +0.50 69
longin
quitat
Pro
Propin
quitat
Add +1.50 +1.50

Pro : M. Raiyan
Umur :44 tahun Banda Aceh , November 2020
Nomor Telepon/Hp 0812 6916 0435
Nomor JKN 0001 8722 3870 8
Diagnosa : Hipermetropia
No Kunjungan Pcare : 010104021120P000879

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50 PL
longin
quitat
Pro
Propin
quitat
Add +2.00 2.00

Pro : Rismawati
Umur : 47 tahun Banda Aceh , 25 November 2020
Nomor Telepon/Hp :
Nomor JKN : 0002430470957
Diagnosa : Hypermetropia (H52.0), Presbyopia (H52.4)
No Kunjungan Pcare :010104021120P000948

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -6.50 -1.00 110 -13.50 -0.75 95
longin
quitat
Pro
Propin
quitat
Add

Pro : Rinaldi
Umur :22 tahun Banda Aceh , 25 November 2020
Nomor Telepon/Hp : 0812 6903 297
Nomor JKN :0000001248581
Diagnosa : Myopia (H52.1), Astigmatism (H52.2)
No Kunjungan Pcare : 010104021120P001002

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0.50 -0.50
longin
quitat
Pro
Propin
quitat
Add +1.50 +1.50

Pro : IDA SAFRIANI

Umur : 46 tahun Banda Aceh , 10 Desember 2020
Nomor Telepon/Hp :
Nomor JKN : 0001437347878
Diagnosa : Myopia , Presbyopia

:
0101040212
No Kunjungan Pcare 20P000305

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50
longin
quitat
Pro
Propin
quitat
Add +!.75

Pro : mirza fuadi

Umur :50 tahun Banda Aceh , 24 november 2020
Nomor Telepon/Hp :
Nomor JKN : 0000164060324
Diagnosa : presbiopia,
No Kunjungan Pcare : 010104021120p001020

(dr sri wahyuni)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1.50 -2.00 60
longin
quitat
Pro
Propin
quitat
Add

Pro : Armaida
Umur : 37 tahun Banda Aceh , 15 Desember 2020
Nomor Telepon/Hp : 0823 6289 5114
Nomor JKN : 0000001082226
Diagnosa : Myopia (H52.1)
No Kunjungan Pcare : 010104021220P000462

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50 +0.50 64/62
longin
quitat
Pro
Propin
quitat
Add +2.00 +2.00

Pro : Azzahari
Umur : 50 tahun Banda Aceh , 19 Desember 2020
Nomor Telepon/Hp :
Nomor JKN : 0000000998616
Diagnosa : Hypermetrop, Presbiopi
No Kunjungan Pcare : 010104021220P000680

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , April 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

1
 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0.25 110
longin
quitat
Pro
Propin
quitat
Add

Pro : Amilatul Fadhilah

Umur : 20 tahun Banda Aceh , 05 Mai 2020
Nomor Telepon/Hp : 0822 7878 8062
Nomor JKN : 0000 0003 8240 8
Diagnosa : Astigmatisma
No Kunjungan Pcare : 0101 0402 0520 P000 024

(dr Niki Febronika)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1,50 -0,75 180 -1,50 0,25 175
longin
quitat
Pro
Propin
quitat
Add

Pro : Nayla Nafisah Bilbina

Umur : 13 tahun Banda Aceh , 05 Mai 2020
Nomor Telepon/Hp : 0852 6012 9161
Nomor JKN : 0000 0012 8326 4
Diagnosa : miopia
No Kunjungan Pcare : 010104020520P000024

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -2.00 -0.50 90 -2.00 -0.25 60
longin
quitat
Pro
Propin
quitat
Add

Pro : Yusrina Ghufrani

Umur : 22 tahun Banda Aceh ,18 Mai 2020
Nomor Telepon/Hp : 0822 8473 5934
Nomor JKN : 0000 0012 8336 5
Diagnosa : Myiopia + Astigmatisma
No Kunjungan Pcare : 010104020520P000384

(dr Sri Wahyuni)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1.50 -1.00 -0.50 65
longin
quitat
Pro
Propin
quitat
Add

Pro : ZIKRA RIZFIANI

Umur : 26 tahun Banda Aceh , 23 Juli 2020
Nomor Telepon/Hp 0852 6077 9957
Nomor JKN :0000001103995
Diagnosa :Myopia (H52.1) + Astigmatisma
No Kunjungan Pcare :010104020720P000853

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -1.50 -1.50 -0.75 10
longin
quitat
Pro
Propin
quitat
Add

Pro : Tiara Aprilia

Umur : 25 tahun Banda Aceh , 24 Juli 2020
Nomor Telepon/Hp : 0822 4352 7452
Nomor JKN : 0000001104006
Diagnosa : Myopia (H52.1)
No Kunjungan Pcare : 010104020720P000878

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin 0.25 90 60
quitat
Pro
Propin
quitat
Add

Pro jumi
Umur : 30 tahun Banda Aceh, 27 Juli 2020
Nomor Telepon/Hp :
Nomor JKN : 0001788021663
Diagnosa : ASTIGMATISMA
No Kunjungan Pcare : 010104020720P001013

(dr Mira Susanti)

34
 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -2.00 -2.00 60
longin
quitat
Pro
Propin
quitat
Add

Pro : NADARA RISKI

Umur : 23 tahun Banda Aceh , 05 Agustus 2020
Nomor Telepon/Hp :
Nomor JKN : 0000001026202
Diagnosa : Myopia (H52.1)
No Kunjungan Pcare :010104020820P000048

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :
 (dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add
Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add
Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
 Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
 longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S
 Color Distant Glass
Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D
 C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

 Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

 90° 90° R/KACAMATA Single Focus
Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

RESEP KACAMATA (HASIL VISUS)

PUSKESMAS BANDA RAYA
 FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , Mai 2020
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,50 -0,50
longin
quitat
Pro
Propin
quitat
Add Add +1,25

Pro : Irwinsyah
Umur : 39 tahun Banda Aceh , 01 September 2020
Nomor Telepon/Hp :
Nomor JKN : 0001296184048
Diagnosa : myopi+ presbiopi
No Kunjungan Pcare : 010104020920P00020

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA

180° 180° 0°
D D

O.D O.S

Color
Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0,50 -0,50
longin
quitat
Pro
Propin
quitat
Add +1,25

Pro : Irwinsyah
Umur : 39 tahun
Nomor Telepon/Hp :
Nomor JKN :0001296184048
Diagnosa : miopy+ presbiopi
No Kunjungan Pcare : 010104020920P00020
 Single Focus
Double Focus

C.10° /15°

Distant Glass

Banda Aceh , 01 September 2020

(dr Mira Susanti)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMATA Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher
Vitrum Cylindr Axis Vitrum Spher
Vitrum Cylindr Axis
Vitor
Pro -6.00 170 60
longin
quitat
Pro
Propin
quitat
Add

MUHAM
MAD
JILAN
MOULA
Pro
Umur : 12 TAHUN Banda Aceh , 30 desember 2020
Nomor Telepon/Hp :-
Nomor JKN 0000199617838
Diagnosa : Astigmatism (H52.2)
No Kunjungan Pcare 010104021220P001065

( dr sri wahyuni )
1.2

0.8

#REF!
#REF!
#REF!
0.6
#REF!
#REF!
#REF!
#REF!

0.4

0.2

0
Series1
1.2

0.8

#REF!
#REF!
#REF!
0.6
#REF!
#REF!
#REF!
#REF!

0.4

0.2

0
Series1
 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMAT Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro -0.50 -0.50 0 61
longin
quitat
Pro
Propin
quitat
Add

:DARA AYU LARASATI SYAHROL

Pro
Umur 27 tahun Banda Aceh , 21 JANUARI 2022
:00014174758
Nomor Telepon/Hp :-
3
Nomor JKN
Diagnosa : MYOPIA
No Kunjungan Pcare :010104020122P001227

(dr. ANDESTA MUTIA ULVA)

 RESEP KACAMATA (HASIL VISUS)
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAMAT Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro
longin
quitat
Pro
Propin
quitat
Add

Pro :
Umur : tahun Banda Aceh , 2021
Nomor Telepon/Hp :
Nomor JKN :
Diagnosa :
No Kunjungan Pcare :

(dr. Dewi Fitriani)

 RESEP KACAMATA (HASIL VISUS )
PUSKESMAS BANDA RAYA

FORMULIR RESEP KACAMATA

90° 90° R/KACAM Single Focus

Double Focus
180° 180° 0°
D D

C.10° /15°
O.D O.S

Color Distant Glass

Vitrum Spher Vitrum Cylindr Axis Vitrum Spher Vitrum Cylindr Axis
Vitor
Pro +0.50 61.5
longin
quitat
Pro
Propin
quitat
Add +1.50 +1.50

Pro : Tuti Asmariati

Umur : 45 Tahun BANDA ACEH 23 JUNI 2022
Nomor Telepon/Hp :-
Nomor JKN : 0001111067188
Diagnosa : Hipermetropia
No Kunjungan Pcare 010104020622P001172

(dr.Andesta Mutia Ulva)

 KODE DIAGNOSA ICD 10

H53 Visual disturbance

H52 Gangguan refraksi
H52.0 Hipermetropia (+) Sph
H52.1 Myopia (-) Sph
H52.2 Astigmatisma (-) Cyl
H52.4 Presbiopia (+) Add
Z46.0 Penyesuaian lensa Rujuk RS