PERMOHONAN DIET PASIEN

( KE INSTALASI GIZI )

Nama : ................................................. ..... .Laki-Laki /Perempuan.

Umur : ........................................................ .Tahun
No. RM : ...............................................................................................
Klinis : ................................................................................................
Hasil Lab : ................................................................................................
Jenis Diet ;

TKTP Tinggi Serat

Lunak( M2) Diabetes

Rendah Lemak Rendah Garam

Tertanda
Dokter Ruang Asoka

(.......................................)
Potong disini

PERMOHONAN DIET PASIEN

( KE INSTALASI GIZI )

Nama : .......................................................................Laki-laki/ Perempuan

Umur : .......................................................................Tahun
No. RM : ........................................................................................................
Klinis : ........................................................................................................
Hasil Lab : ........................................................................................................

TKTP Tinggi Serat

Lunak( M2) Diabetes

Rendah Lemak Rendah Garam

Tertanda
Dokter Ruang Asoka

(.......................................)