Form Swamed.docx

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DOKUMENTASI SWAMEDIKASI Nama Pasien Jenis Kelamin

P / L *)

Usia Alamat Tanggal pasien datang Keluhan pasien

Riwayat alergi Pasen pernah datang sebelumnya :

Ya / tidak*) OBAT YANG DIBERIKAN :

Nama Obat

Dosis

Cara pemakaian

No Batch

Tanggal ED

1 2 3 4 *) coret salah satu Surakarta, ………………………………….. 2019 Yang menyerahkan,

……………………………………………………………….

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