DINAS KESEHATAN
UPT PUSKESMAS KRAGILAN
JL. Raya Jakarta – Serang KM. 15 No. 83 Kragilan – Serang Kode Pos : 42184
Email : puskesmaskragilan@gmail.com
NOMOR : 002589
Nama : ...............................................................
Alamat : ...............................................................
Kragilan,...................... 20......
Catatan :
Tinggi Badan : ……… cm
Berat Badan : ……… kg (Dr. ................................)
Tensi : ……… mm/hg