SURAT KONTROL SURAT KONTROL SURAT KONTROL

PRO TS DR.POLIKLINIK PRO TS DR.POLIKLINIK PRO TS DR.POLIKLINIK

Klinik Surya Medika PKU Muhammadiyah Sumbawa Klinik Surya Medika PKU Muhammadiyah Sumbawa Klinik Surya Medika PKU Muhammadiyah Sumbawa

Menghadap penderita : Menghadap penderita : Menghadap penderita :

NAMA : ............................................................ L/P NAMA : ............................................................ L/P NAMA : ............................................................ L/P

UMUR : ................................................Th / Bl / Hr UMUR : ................................................Th / Bl / Hr UMUR : ................................................Th / Bl / Hr

MRS TGL : ................................................................. MRS TGL : ................................................................. MRS TGL : .................................................................

DIAGNOSIS : ................................................................. DIAGNOSIS : ................................................................. DIAGNOSIS : .................................................................

................................................................. ................................................................. .................................................................

................................................................. ................................................................. .................................................................

TERAPI : ................................................................. TERAPI : ................................................................. TERAPI : .................................................................

HASIL LAB : ................................................................. HASIL LAB : ................................................................. HASIL LAB : .................................................................

................................................................. ................................................................. .................................................................

HASIL RO : ................................................................ HASIL RO : ................................................................ HASIL RO : ................................................................

Atas kerjasamanya disampaikan terimakasih Atas kerjasamanya disampaikan terimakasih Atas kerjasamanya disampaikan terimakasih

Sumbawa, .................................. Sumbawa, .................................. Sumbawa, ..................................

DOKTER DPJP DOKTER DPJP DOKTER DPJP

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