NRM :

Nama :

Jl. Tanah Abang 3 No.18A Tanggal Lahir :

Jakarta Pusat 10160
Telp: 021-3841919, 3803558, 3503033 Jenis Kelamin :

SURAT KONTROL
Mohon kontrol pasien

Diagnosa :…………………………………………………………………………………………………………………………….........

Tindakan : …………………………………………………………………………………………………………………………….........
Terapi :…………………………………………………………………………………………………………………………….........
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Ket. Lain : …………………………………………………………………………………………………………………………….........

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Tanggal kontrol :…………………………………………………………………………………………………………………………....

Klinik Spesialis Tujuan : Penyakit Dalam Kulit dan Kelamin

Anak Gigi
Paru Rehabilitasi Medik
Bedah Plastik Lain-lain…………………….
Bedah Saraf

Catatan : Jakarta, .................................

Tgl. Hasil PA :....................... Dokter,

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Tanda tangan & Nama terang