Surat Kontrol

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KLINIK PRATAMA “AMAL SEHAT”

Desa Sadang Rt 04 Rw 04 No. 44 A Jekulo Kudus Telp. (0291) 5708293 e-mail : amal.sehat@yahoo.com

SURAT KONTROL BEROBAT

Nama Pasien : …………………………………………………………………………

Umur : …………………………………………………………………………

Alamat : …………………………………………………………………………

Diagnosis :………………………………………………………………………….

Dokter yang Merawat : …………………………………………………………………………

Tanggal : ………………………………...s/d …………………………………...

Obat Injeksi : …………………………………………………………………………

…………………………………………………………………………

Obat Oral & OP : …………………………………………………………………………

…………………………………………………………………………

.…………………………………………………………………………

………………………………………………………………………….

Saran : ………………………………………………………………………….

………………………………………………………………………….

Kudus,

Perawat Pelaksana Kepala Ruang

( ) ( Rayan Adha Juliyanto. AMK

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