Status Gigi
Status Gigi
DINAS KESEHATAN
PUSKESMAS BAGOANG
Jln. Letnan Sayuti KM 08 Desa Bagoang Kecamatan Jasinga Kode Pos 16670
Telp (0251) 8688188 email : bagoangpuskesmas@gmail.com
No. RM
DATA PASIEN
No. BPJS/JKN : .............................................
Nama : .............................................
Nama Ibu/Ayah : Ibu ....................................... Ayah ....................................................
Jenis Kelamin : .............................................
Tempat/Tanggal Lahir : .............................................
Alamat : .............................................
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Telepon : ............................................. Cacat ..................................................
Pekerjaan : ............................................. Penyakit/Kelainan ..............................
Nama Orang Tua : ............................................. Dalam keluarga ..................................
(Jika Pasien Anak) Riwayat Alergi ....................................
Penyakit penting ...............................