KLINIK MEDISTRA

PERMOHONAN Legalisasi Gigi Palsu

Jl. S. Parman Mo.28 Tanah Patah Bengkulu
Informasi : (0736) 346719

KARTU REKAM MEDIS PASIEN

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

Tempat/Tanggal Lahir : .........................................................................................
Orang Tua/Suami : .........................................................................................
Agama : .........................................................................................
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Alamat Rumah : .........................................................................................
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Alamat Kantor : .........................................................................................
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DIKIRIM : TGL : ALLERGI :

PEMERIKSAAN GIGI/GELIGI :

1.8 1.7 1.6 1.5 1.4 1.3 1.2 1.1 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8
4.8 4.7 4.6 4.5 4.4 4.3 4.2 4.1 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8

PENYAKIT SISTEMIK : YA TIDAK

RADIX YA TIDAK

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