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PEMERINTAH KABUPATEN KAMPAR

DINAS KESEHATAN
UPT PUSKESMAS PETAPAHAN
KECAMATAN TAPUNG
Jalan Raya Petapahan-Pekanbaru, Telp/ WA: 081270870575
E-mail: pkmtapung.1@gmail.com Facebook: Puskesmas Tapung 1
Kode Pos 28464

RESUME MEDIS RAWAT JALAN

No. Rekam Medis :

Nama Pasien : ................................................................................................................................................................


Tanggal Lahir : ................................................................................................................................................................
Tanggal Pemeriksaan : Anjuran :
Klinik / Dokter

:
Lembar untuk diisi dokter
Anamnesa :

Diagnosa :

Terapi :
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Dengan ini saya selaku pasien / tertanggung, mengizinkan Puskesmas Petapahan untuk memberikan keterangan lengkap
mengenai keadaan penyakit / data medis kepada pihak ketiga yang ditunjuk secara sah.

( (
Pasien ) Pasien / Tertanggung ) Dokter
Arsip
Perusahaan

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