Anda di halaman 1dari 1

RUMAH SAKIT UMUM ADHYAKSA

Jl.Hankam Raya No.60, Ceger, Jakarta


Timur, Telp.021-29462345, Fax.021-
29462370
Email :adhyaksarsua@gmail.com

FORMULIR RESEP KACAMATA


No. ……………./ RSUA / ………….. / 20 ……..

Progressive
Bifocus
Biasa

Vitrum Vitrum Prisma Vitrum Vitrum Prisma Forma Color Distant


Axis Axis
Spher Cylndr Basis Spher Cylndr Basis Vitror Vitror Vitror
Pro
login
quitat
Pro
domo
Pro
Propin
quitat

Nama : ……………………………………
Umur : ……………………………………
Jakarta,.................................,20 …

( dr...............................................)

Anda mungkin juga menyukai