Anda di halaman 1dari 1

Y A Y A S A N P E L A Y A N A N K A S I H AG U S T I N I A N Y AYASAN PELAY ANA N K ASIH AGUSTI NIAN

RUMAH SAKIT S UM BE R SE NT OSA RUMAH SAKIT S UM BE R SE NT OSA


Jl.RayaKebonsari No. 221, Tumpang, Malang, JawaTimur 65156 Jl.RayaKebonsari No. 221, Tumpang, Malang, JawaTimur 65156
Telp. 0341 – 787233 Fax. 0341 – 786756,Email :rsss.tumpang@rocketmail.com Telp. 0341 – 787233 Fax. 0341 – 786756,Email :rsss.tumpang@rocketmail.com
“ MelayaniDalamK asi h” “ MelayaniDalamK asi h”

SURAT KONTROL SURAT KONTROL


No : ........................................................... No : ............................................................

Untuk : ............................................................................................ Untuk : ............................................................................................


Umur : ............................................................................................ Umur : ............................................................................................
Alamat : ............................................................................................ Alamat : ............................................................................................

Mohon konsultasi / kontrol besok pada : Mohon konsultasi / kontrol besok pada :

Hari / Tanggal : ............................................................................................ Hari / Tanggal : ............................................................................................


Di : ............................................................................................ Di : ............................................................................................
No.Antrian : ............................................................................................ No.Antrian : ............................................................................................
Dx (Diagnosa): ............................................................................................ Dx (Diagnosa): ............................................................................................

Malang,......................... Malang, ........................


Hormat Saya Hormat Saya

dr....................................... dr......................................

Anda mungkin juga menyukai