PURNAMASARI HOSPITAL

ADMINISION CARD

Identity according to identification (KTP, SIM, etc.)

Patient data

Full name : Nikomang Sinta Purnamasari

Date and place of birth : Toinasa June 24, 2002

Sex : L * P

Address : Toinasa village

Hp : 082296698268

Religion : Hindu

Tribe : Bali

Languages used in everyday life: Indonesian

Status : Single

Education : Senior high school

Job : Nursing Student

Citizenship : Indonesian

Height : 156 cm

Weight : 69 kg

Email : nikomangsintapurnamasari@gmail.com

I hereby agree to carry out examinations and necessary actions in an effort to heal / save my soul / the
patient
Person in charge
Name : Inyoman Panitra

Address : Toinasa village

Phone : 082245467220

Payment method : BPJS

Date of arrival : June 1, 2021

That states registration officer

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Signature & clear name Signature & clear name