PEMERINTAH KOTA PALANGKA RAYA

RUMAH SAKIT UMUM KELAS D

KOTA PALANGKA RAYA
Jl. MahirMahar Km. 18,5Telp. (0536) 3246101 Kalampangan 73114
Email.rsupalangkaraya@gmail.com

FORMULIR PEMERIKSAAN ODONTOGRAM

RM A.2
NAMA LENGKAP :..............................................
TANGGAL LAHIR :..............................................
NO. RM :..............................................
PEKERJAAN :..............................................
GOL DARAH :..............................................
NO TELP/HP :..............................................
JENIS KELAMIN :..............................................

18 28
17 27
16 26
15 [55] [65] 25
14 [54] [64] 24
13 [53] [63] 23
12 [52] [62] 22
11 [51] [61] 21

48 38
47 37
46 36
45 [85] [75] 35
44 [84] [74] 34
43 [83] [73] 33
42 [82] [72] 32
41 [81] [71] 31

Keterangan lebih lanjut (Oklusi, Torus, Ortho, dll):

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DIPERIKSA OLEH : PADA TANGGAL : TANDA TANGAN :

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INFUT DIGITAL :