Form RM.08/RJ/Rev.

1/2018
Nomor RM :

Nama : ............................................................
RUMAH SAKIT ISLAM KARAWANG
Jln. Pangkal Perjuangan Km. 2 By Pass Karawang
Telp. (0267) 414520, 414521 Fex : (0267) 413277
e-mail : rsi_karawang@yahoo.com

Tanggal Lahir : ............................................................

Jenis Kelamin : L / P )*
FORMULIR RESEP Tgl. Masuk : .............../............../.............................
KACAMATA Alamat : ............................................................
............................................................

Biasa
Bifokal

Gelas S…………………………….……..C……………………………………ax…………………………...…….....°
Kanan S…………………………………...C……………………………………ax…………………………...…….....°
Gelas S……………………………………C……………………………………ax……………………………...…....°
Kiri S……………………………………C……………………………………ax…………………………………...°

Distatia Pupilaris………………………………/……………………………………mm

Karawang,……….……………20…
Dokter Pemeriksa

(…………………………………….)

Nomor RM :

Nama : ............................................................
RUMAH SAKIT ISLAM KARAWANG
Jln. Pangkal Perjuangan Km. 2 By Pass Karawang
Telp. (0267) 414520, 414521 Fex : (0267) 413277
e-mail : rsi_karawang@yahoo.com

Tanggal Lahir : ............................................................

Jenis Kelamin : L / P )*
FORMULIR RESEP Tgl. Masuk : .............../............../.............................
KACAMATA Alamat : ............................................................
............................................................

Biasa
Bifokal

Gelas S…………………………….……..C……………………………………ax…………………………...…….....°
Kanan S…………………………………...C……………………………………ax…………………………...…….....°
Gelas S……………………………………C……………………………………ax……………………………...…....°
Kiri S……………………………………C……………………………………ax…………………………………...°
 Form RM.08/RJ/Rev.1/2018
Distatia Pupilaris………………………………/……………………………………mm

Karawang,……….……………20…
Dokter Pemeriksa

(…………………………………….)