No. LPO : ..................................................................... Tgl : .................... No. LPO : ..................................................................... Tgl : ......................
Nama Petugas : ..................................................................... Nama Petugas : .....................................................................
SIPP / SIPB : ..................................................................... SIPP / SIPB : .....................................................................
Unit / Poli : ..................................................................... Unit / Poli : .....................................................................
DX : ..................................................................... DX : .....................................................................
Dosis Dosis
No Nama Obat Sediaan Jumlah Obat Paraf No Nama Obat Sediaan Jumlah Obat Paraf
Pemakaian Pemakaian