surat kontrol ri.docx
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PUSKESMAS IV DENPASAR SELATANRUANG RAWAT INAP
SURAT KONTROL
RAWAT INAP UMUM No: .…../KTRL/RI/DSIV/….../…….. Tgl:
NAMA PASIEN :…………………………..................................................UMUR :…………………………..................................................ALAMAT :………………………………………………………….DIAGNOSIS :………………………………………………………….TINDAKAN :………………………………………………………….TERAPI :……………………………. .
……………………………..……………………………..……………………………...……………………………..
MOHON KONTROL KEMBALI KE POLIKLINIK :……………………………PADA TANGGAL: ………………………
DENPASAR,…………………PETUGAS RAWAT INAP
(……………………………….)
PUSKESMAS IV DENPASAR SELATANRUANG RAWAT INAP
SURAT KONTROL
RAWAT INAP UMUM No: .…../KTRL/RI/DSIV/….../…….. Tgl:
NAMA PASIEN :…………………………..................................................UMUR :…………………………..................................................ALAMAT :………………………………………………………….DIAGNOSIS :………………………………………………………….TINDAKAN :………………………………………………………….TERAPI :………………………………………………………….
…………………………………………………………..………………………………………………………….…………………………….............................................
MOHON KONTROL KEMBALI KE POLIKLINIK :……………………………PADA TANGGAL: ………………………
DENPASAR,…………………PETUGAS RAWAT INAP
(……………………………….)
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