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PEMERINTAH KABUPATEN BERAU DINAS KESEHATAN

PUSKESMAS TANJUNG REDEB Jl. Rambutan No. 377 Telp. 21013 Kel. Tanjung Redeb Kec. Tanjung Redeb 77311

PERMOHONAN PEMERIKSAAN KESEHATAN CALON JAMAAH HAJI 1. 2. 3. 4.

Nama Tanggal Lahir Alamat No Hp

: : : :

Pemeriksaan meliputi : a. Darah Lengkap b. Urin c. SGOT/SGPT d. Cholestrol lengkap e. URCR f. GDP g. HbsAg h. RO+Konsul i. EKG+Konsul j. LED k. Asam Urat Demikian atas bantuannya, diucapkan terimakasih.

Salam Sejawat,

2018

…………………………………… NIP.

PEMERINTAH KABUPATEN BERAU DINAS KESEHATAN

PUSKESMAS TANJUNG REDEB Jl. Rambutan No. 377 Telp. 21013 Kel. Tanjung Redeb Kec. Tanjung Redeb 77311

PERMOHONAN PEMERIKSAAN KESEHATAN CALON JAMAAH HAJI 5. 6. 7. 8.

Nama : Tanggal Lahir : Alamat : No Hp : Pemeriksaan meliputi : a. b. c. d. e. f. g. h. i. j. k.

Darah Lengkap Urin SGOT/SGPT Cholestrol lengkap URCR GDP HbsAg RO+Konsul EKG+Konsul LED Asam Urat Demikian atas bantuannya, diucapkan terimakasih.

Salam Sejawat,

…………………………………… NIP.

2018

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