RUMAH SAKIT UMUM RUMAH SAKIT UMUM RUMAH SAKIT UMUM

PERMATA MADINA PANYABUNGAN PERMATA MADINA PANYABUNGAN PERMATA MADINA PANYABUNGAN

Jl. Merdeka No. 155 Kelurahan Kayu Jati, Kecamatan Panyabungan, Jl. Merdeka No. 155 Kelurahan Kayu Jati, Kecamatan Panyabungan, Jl. Merdeka No. 155 Kelurahan Kayu Jati, Kecamatan Panyabungan,
Kabupaten Mandailing Natal, Propinsi Sumatera Utara, Indonesia, Kabupaten Mandailing Natal, Propinsi Sumatera Utara, Indonesia, Kabupaten Mandailing Natal, Propinsi Sumatera Utara, Indonesia,
Kode Pos 22919, Telp. (0636) 20279, Fax (0636) 20712 Kode Pos 22919, Telp. (0636) 20279, Fax (0636) 20712 Kode Pos 22919, Telp. (0636) 20279, Fax (0636) 20712
Email : rspm155@gmail.com Email : rspm155@gmail.com Email : rspm155@gmail.com

Tanggal : ............................................ Tanggal : ............................................ Tanggal : ............................................

Ruangan/Poliklinik Riwayat Alergi Obat : Ruangan/Poliklinik Riwayat Alergi Obat : Ruangan/Poliklinik Riwayat Alergi Obat :
......................................................... Tidak ......................................................... Tidak ......................................................... Tidak

Ya, Nama Obat ......................... Ya, Nama Obat ........................... Ya, Nama Obat ...........................

RI RI RI

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

No Rekam Medis : ............................................................................................... No Rekam Medis : ............................................................................................... No Rekam Medis : ...............................................................................................
Tanggal Lahir/Umur : ............................................................................................... Tanggal Lahir/Umur : ............................................................................................... Tanggal Lahir/Umur : ...............................................................................................
Berat Badan : ............................................................................................... Berat Badan : ............................................................................................... Berat Badan : ...............................................................................................
Nama Dokter : ............................................................................................... Nama Dokter : ............................................................................................... Nama Dokter : ...............................................................................................
Paraf Dokter : ............................................................................................... Paraf Dokter : ............................................................................................... Paraf Dokter : ...............................................................................................

Obat ini tidak boleh diganti tanpa seizin dokter Obat ini tidak boleh diganti tanpa seizin dokter Obat ini tidak boleh diganti tanpa seizin dokter