FORMULIR OBAT KHUSUS

FOI PT. AJ INHEALTH INDONESIA

1. Data penderita
Nomor KP Inhealth : ……………………………………………………………………………………………….
Nama Penderita : ……………………………………………………………………………………………….
Umur Penderita :
……………………………………………………………………………………………….
Status Penderita : Peserta / Istri / Suami / Anak
2. Diagnosa : ……………………………………………………………………………………………….

……………………………………………………………………………………………….

……………………………………………………………………………………………….
3. Alasan terapi : ……………………………………………………………………………………………….

……………………………………………………………………………………………….

………………………………………………………………………………………………..
4. Obat khusus di Dalam FOI PT. Inhealth yang diminta :
No Nama Obat Jumlah Dosis Lama pemberian

Surabaya, ………………………………
Mengetahui, Dokter yang merawat,
PRO RS……………………………….,

(…………………………………………) (…………………………………………)