Surat Izin Meninggalkan Puskesmas.docx
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PEMERINTAH DAERAH KABUPATEN TASIKMALAYA
DINAS KESEHATAN UPT PUSKESMAS CIPATUJAH
Jalan Raya Cipatujah Nomor : 123 Telepon : (0265) 7580480 Website : [email protected] e-mail : [email protected] Cipatujah – 46189
No. RM :
SURAT IZIN MENINGGALKAN PUSKESMAS NO : ........................................................................
Nama
: ............................................................. Umur : .........
Jenis Kelamin : L / P
Alamat
: ............................................................................................................................. .............................................................................................................................
Tanggal Masuk
: .............................................................................................................................
Diagnosa Akhir
: ............................................................................................................................. .............................................................................................................................
Pengobatan
: ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. .............................................................................................................................
Pemeriksaan
: ............................................................................................................................. ............................................................................................................................. .............................................................................................................................
Keterangan
: Sembuh / Belum Sembuh / Perbaikan
Nasehat
: ............................................................................................................................. .............................................................................................................................
PERHATIAN
: SETIAP AKAN BEROBAT KARTU INI HARUS DIBAWA
Cipatujah, .............................................. 20 .... Dokter Pemeriksa
( ...................................................................... ) NIP : ..............................................................
DINAS KESEHATAN UPT PUSKESMAS CIPATUJAH
Jalan Raya Cipatujah Nomor : 123 Telepon : (0265) 7580480 Website : [email protected] e-mail : [email protected] Cipatujah – 46189
No. RM :
SURAT IZIN MENINGGALKAN PUSKESMAS NO : ........................................................................
Nama
: ............................................................. Umur : .........
Jenis Kelamin : L / P
Alamat
: ............................................................................................................................. .............................................................................................................................
Tanggal Masuk
: .............................................................................................................................
Diagnosa Akhir
: ............................................................................................................................. .............................................................................................................................
Pengobatan
: ............................................................................................................................. ............................................................................................................................. ............................................................................................................................. .............................................................................................................................
Pemeriksaan
: ............................................................................................................................. ............................................................................................................................. .............................................................................................................................
Keterangan
: Sembuh / Belum Sembuh / Perbaikan
Nasehat
: ............................................................................................................................. .............................................................................................................................
PERHATIAN
: SETIAP AKAN BEROBAT KARTU INI HARUS DIBAWA
Cipatujah, .............................................. 20 .... Dokter Pemeriksa
( ...................................................................... ) NIP : ..............................................................
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