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  • Surat Ijin Keluar

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    Surat Ijin Keluar

    Diunggah oleh

    rstrimedikaketapang

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    © All Rights Reserved
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    dari 1

    Klinik Pratama Rawat Inap Klinik Pratama Rawat Inap

    Panti Agape Grobogan Panti Agape Grobogan


    Jl. Pangeran Puger (Jalan Raya Purwodadi-Pati Km. 6), Grobogan, Jawa Tengah Jl. Pangeran Puger (Jalan Raya Purwodadi-Pati Km. 6), Grobogan, Jawa Tengah

    SURAT IIJIN KELUAR SURAT IIJIN KELUAR

    NO. RM : ................................................................................................................. NO. RM : .................................................................................................................


    Nama : ................................................................................................................. Nama : .................................................................................................................
    Umur : ................................................................................................................. Umur : .................................................................................................................
    Ruang : ................................................................................................................. Ruang : .................................................................................................................
    Alamat : ................................................................................................................. Alamat : .................................................................................................................
    Telah DIIJINKAN KELUAR dari Klinik Panti Agape Grobogan Telah DIIJINKAN KELUAR dari Klinik Panti Agape Grobogan
    Cara keluar : ................................................................................................................. Cara keluar : .................................................................................................................
    Diagnosis : ................................................................................................................. Diagnosis : .................................................................................................................
    Terapi : ................................................................................................................. Terapi : .................................................................................................................
    Penyebab : ................................................................................................................. Penyebab : .................................................................................................................
    Kecelakaan : ................................................................................................................. Kecelakaan : .................................................................................................................

    ALERGI OBAT ALERGI OBAT

    *BTA : +/- 1. ............................................................. *BTA : +/- 5. .............................................................


    *Imunisasi : 2. ............................................................. *Imunisasi : 6. .............................................................
    3. ............................................................. 7. .............................................................
     Campak : 4. .............................................................  Campak : 8. .............................................................
     TBC :  TBC :
     Dipteri : Grobogan,.............................................. 20  Dipteri : Grobogan,.............................................. 20
    Klinik Panti Agape Grobogan Klinik Panti Agape Grobogan

    (..............................................) (..............................................)

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