Drg.

Febrina Susilawati

Sip. 440/0137.2I D O l X l 2013

Bekasi,.........................................................
l.Konsultasi
7.

'l-p ?0 -000
p^r\gan

fLp. 60-000
- 0-(30D

VT/ rt ftx pe

((^7 - ppT'-OOO

4: -

'T a.mtCTi!, .n fern-eri't'^*'"'5'

ftp - PD-000

5-

T"<o^y\b>o( (an

rup - ^fr-coo
rvp ,-110-000

G
.

feAanvS

*-4'(o>-'+ Cur-e t W(0 c; |

5&L-e*n5
ke^Cr-

V
2
>
3
-10

Nama :
Usia :

rUL 5 ee/ nv^ctn

pi> &. plppcy-* Peatctar
Polp capping
. Pp/V ' W 1005^1

Op - i5~O-000
n^> - "IOD-CCCO
n* -iro-o^o
(Vp- 7-00'006
(O-p . 3-S '006
Op- (T'OOO
Op ^-000
Op - 000

S'arvtc*

Rp l25000

Pengisian

Rp 100000