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No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th.
OBAT LUAR OBAT LUAR OBAT LUAR OBAT LUAR

Nama/ Jumlah Obat : Nama/ Jumlah Obat : Nama/ Jumlah Obat : Nama/ Jumlah Obat :
Tgl. ED : Tgl. ED : Tgl. ED : Tgl. ED :



SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001
APA : apt. Mutia Harsella, S.Farm APA : apt. Mutia Harsella, S.Farm APA : apt. Mutia Harsella, S.Farm APA : apt. Mutia Harsella, S.Farm
SIPA : 440/701165292/SIPA/DPMPTSP/I/2022 SIPA : 440/701165292/SIPA/DPMPTSP/I/2022 SIPA : 440/701165292/SIPA/DPMPTSP/I/2022 SIPA : 440/701165292/SIPA/DPMPTSP/I/2022
Alamat : Jl Batang Hari No. 5 Nusa Indah, Ratu Agung, Kota Bengkulu Alamat : Jl Batang Hari No. 5 Nusa Indah, Ratu Agung, Kota Bengkulu Alamat : Jl Batang Hari No. 5 Nusa Indah, Ratu Agung, Kota Bengkulu Alamat : Jl Batang Hari No. 5 Nusa Indah, Ratu Agung, Kota Bengkulu
No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl...............................

Nama :.................... Pagi Nama :.................... Pagi Nama :.................... Pagi Nama :.................... Pagi
Siang Siang Siang Siang
Sore Sore Sore Sore
Malam Malam Malam Malam
.............X Sehari .............. .............X Sehari .............. .............X Sehari .............. .............X Sehari ..............
Tablet /Capsul /Bungkus Tablet /Capsul /Bungkus Tablet /Capsul /Bungkus Tablet /Capsul /Bungkus
Sebelum /Sesudah /Bersama Makan Sebelum /Sesudah /Bersama Makan Sebelum /Sesudah /Bersama Makan Sebelum /Sesudah /Bersama Makan
SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001


Sore Sore Sore Sore
SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001


Sore Sore Sore Sore
SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001


Sore Sore Sore Sore

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No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th.

OBAT LUAR OBAT LUAR OBAT LUAR OBAT LUAR

No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th.

OBAT LUAR OBAT LUAR OBAT LUAR OBAT LUAR

No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th.

OBAT LUAR OBAT LUAR OBAT LUAR OBAT LUAR

No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th. No.............................. Tgl........................Th.

OBAT LUAR OBAT LUAR OBAT LUAR OBAT LUAR

No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl...............................

SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001

No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl...............................

SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001

No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl...............................

SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001 SIA : 18122100037130001

No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl............................... No .............................. Tgl...............................

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