Medical Practitioner's detail: | _ | i a LEE eee l Eas i Name: | Onset date when symptoms frst noticed by patient: When did the patient First see a doctor? . Details of treatment: [ Details of operation: [eta cof medication (i a Dental treatment | Annual check Oo Preventive Oo Major restorative c Oo Orthodontics Oo ‘Asident / emergency treatment O° Deototvamens | “Gl Kes a perio dentin —> 7 Cin cee S10 A+ Prins Soe Hespitaldates Admissondate: [0 ]o[»]u Te Oschargedste [>>] ue] [or] Name and addres of admitting hospital Reference number | 7 ‘we [| LT] s | |RUMAA SAKIT 1F PURI CINERE 1 Marl Pu Cin 6 Koya Dep Indonesia Telepon: (6221) T8465, Fax. (6221) 7345490 s7eag4 angen ‘umum) Sar (Umum) Konsut Ruman Sakdt Poll Gig! (DIR 8286 1610-61 Saido Akhir o 004 4) BURI CINERE Bash 1 Bu Ci BAH Koy Dek Inonsia ‘elopon (62-21) 145488, Fax, (6221) 7345490. 120.000,20 4 aiINlAs 2.aoct 2015 UMAH S PURI cis 002/ KEU/1/ 06 LULAN JUWITA TRAN am Medis -600 MG CaP {Grace Total Bia Fembsyaren Kartu Krecit 510-6707 33: jahvadl, Dra] AB (Grace Tiahjsd Harps Rp 42,808.23 RUMAH Se 19 PURI CIN (002 /KEU/1/ 06