KARTU KONTROL KARTU KONTROL

PLP  PLP 
PLS  PLS 

No. SIKDA : ................................................. No. SIKDA : .................................................

Nama : ................................................. Nama : .................................................

Umur : ................................................. Umur : .................................................

Alamat : ................................................. Alamat : .................................................

KRS : ......................... TGL ............... KRS : ......................... TGL ...............

Diagnosa : ................................................. Diagnosa : .................................................

Therapy : ................................................. Therapy : .................................................

KONTROL HARI :................... TGL ............... KONTROL HARI :................... TGL ...............

Pasien, Petugas, Pasien, Petugas,

................... ................... ................... ...................

Dokter Dokter

................... ...................

KARTU KONTROL KARTU KONTROL

PLP  PLP 
PLS  PLS 

No. SIKDA : ................................................. No. SIKDA : .................................................

Nama : ................................................. Nama : .................................................

Umur : ................................................. Umur : .................................................

Alamat : ................................................. Alamat : .................................................

KRS : ......................... TGL ............... KRS : ......................... TGL ...............

Diagnosa : ................................................. Diagnosa : .................................................

Therapy : ................................................. Therapy : .................................................

KONTROL HARI :................... TGL ............... KONTROL HARI :................... TGL ...............

Pasien, Petugas, Pasien, Petugas,

................... ................... ................... ...................

Dokter Dokter

................... ...................