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DATA- PAS I E N

GANGGUAN PENGLIHATAN
TAHUN ............

NO TGL N A M A - PENDERITA JENIS KELAMIN UMUR

L P
1 2 3 5 6 7
DATA- PAS I E N
ANGGUAN PENGLIHATAN
TAHUN ............

ALAMAT RT/RW KUNJUNGAN PENGOBATAN KET.

BARU LAMA
8 9 10 11 12

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