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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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