Nama : Nama :
Umur : Umur :
Status : Status :
No Nama Obat Qty Harga Jumlah No Nama Obat Qty Harga Jumlah
1 1
2 2
3 3
4 4
5 5
6 6
7 7
8 8
9 9
10 10
Tuslah Tuslah
TOTAL TOTAL
Palopo. 20 Palopo. 20
JUMLAH JUMLAH
Palopo 2022 Palopo 2022
Penanggung Petugas Penanggung Petugas
No.
R S M UJ AI S Y AH No.
R S M UJ AI S Y AH
JL. DR. RATULANGI KM.5 POROS BALANDAI JL. DR. RATULANGI KM.5 POROS BALANDAI
KOTA PALOPO KOTA PALOPO
Telp .0471-3311727 Telp .0471-3311727
JUMLAH JUMLAH
Palopo, 2022 Palopo, 2022
Penanggung Petugas Penanggung Petugas
NO. RM
Nama : ................................................................ Telpon/HP : ........................................................................
Alamat : ................................................................ SEX : ........................................................................
Umur : ................................................................ AGAMA : ........................................................................
Tempat/ T.L : ................................................................ PEKERJAAN : ........................................................................
Tanggal DESCRIPTION TINDAKAN KET
NO. RM
Nama : ................................................................ Telpon/HP : ........................................................................
Alamat : ................................................................ SEX : ........................................................................
Umur : ................................................................ AGAMA : ........................................................................
Tempat/ T.L : ................................................................ PEKERJAAN : ........................................................................
Tanggal DESCRIPTION TINDAKAN KET