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PEMERINTAH KABUPATEN KUTAI BARAT PEMERINTAH KABUPATEN KUTAI BARAT

DINAS KESEHATAN DINAS KESEHATAN


UPT .PUSKESMAS MUARA PAHU UPT .PUSKESMAS MUARA PAHU
Jln. Raden Baroh RT.VI No.59 Kp. Tanjung Laong Kecamatan Muara Pahu Kode Pos 75574 Jln. Raden Baroh RT.VI No.59 Kp. Tanjung Laong Kecamatan Muara Pahu Kode Pos 75574

LEMBAR PERMINTAAN OBAT LEMBAR PERMINTAAN OBAT

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

Nama Pasien : .......................................................... L / P Nama Pasien : .......................................................... L / P


Umur : .......................................................... BB : . . .Kg Umur : .......................................................... BB : . . .Kg
Alamat / No.HP : .......................................................... Alamat / No.HP : ..........................................................
Jaminan : Umum KIS/BPJS AS PG ....................... Jaminan : Umum KIS/BPJS AS PG .......................

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