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BUKTI PELAYANAN PERSALINAN

KLINIK..................................................

Nama Pasien :............................................................................................................................


No. Kartu :............................................................................................................................
Umur :............................................................................................................................
No. Telp / HP :............................................................................................................................
Diagnosa :............................................................................................................................
Tindakan :............................................................................................................................
Waktu Persalinan :............................................................................................................................
BB Bayi :............................................................................................................................
Keterangan :............................................................................................................................

Pasuruan, ............................................

Peserta , Bidan yang merawat,

(.................................................) (Teguh Purwanti, AMd. Keb)

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