Formulir Kritik Dan Saran.docx

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DINAS KESEHATAN KABUPATEN AGAM PUSKESMAS BASO Jalan Raya Payakumbuh – Bukittinggi KM. 11 Baso Telp. (0752) 426169

Kode Pos 26192

FORMULIR KRITIK DAN SARAN Ditujukan Ke Poli : Kritik :

Saran :

Tanggal

:……………………………………………

No Tlep/HP :…………………………………………..

Nama / Umur :……………………………………………… Alamat

:………………………………………………

DINAS KESEHATAN KABUPATEN AGAM PUSKESMAS BASO Jalan Raya Payakumbuh – Bukittinggi KM. 11 Baso Telp. (0752) 426169

Kode Pos 26192

FORMULIR KRITIK DAN SARAN Ditujukan Ke Poli : Kritik :

Saran :

Tanggal

:……………………………………………

No Tlep/HP :…………………………………………..

Nama / Umur :……………………………………………… Alamat

:………………………………………………

DINAS KESEHATAN KABUPATEN AGAM PUSKESMAS BASO Jalan Raya Payakumbuh – Bukittinggi KM. 11 Baso Telp. (0752) 426169

Kode Pos 26192

FORMULIR KRITIK DAN SARAN Ditujukan Ke Poli : Kritik :

Saran :

Tanggal

:……………………………………………

No Tlep/HP :…………………………………………..

Nama / Umur :……………………………………………… Alamat

:………………………………………………

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