KARTU PELAYANAN KELUARGA BERENCANA (KB)

BAGI PESERTA BPJS KESEHATAN

Nama : .................................................................... Alamat : ................................................................................
Tanggal Lahir : .................................................................... ................................................................................
Nomor Kartu : .................................................................... Nomor Ponsel : .................................................................................

Jenis KB Keluhan
No. Tgl Pelayanan Saran Perawat Keterangan TTD Pasien
(merk dicantumkan) (bila ada)
Ingat tgl kembali suntik KB

Tanda Tangan Pemeriksa,

Perawat

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