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  • RS MITRA KELUARGA - Masyithah K.P.F 1130022118

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    kiyokth19
    5 views2 pages
    To open and submit this form, you need to use Adobe Acrobat Reader. The form requests basic patient information like name, address, phone number, and diagnosis for medical record purposes. Selecting the appropriate ICD code versions is also necessary to submit the form.

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    Original Title

    RS MITRA KELUARGA_Masyithah K.P.F 1130022118

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    To open and submit this form, you need to use Adobe Acrobat Reader. The form requests basic patient information like name, address, phone number, and diagnosis for medical record purposes. Selecting the appropriate ICD code versions is also necessary to submit the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    5 views2 pages

    RS MITRA KELUARGA - Masyithah K.P.F 1130022118

    Uploaded by

    kiyokth19
    To open and submit this form, you need to use Adobe Acrobat Reader. The form requests basic patient information like name, address, phone number, and diagnosis for medical record purposes. Selecting the appropriate ICD code versions is also necessary to submit the form.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 2

    In order to submit this form, you should open it with Adobe Acrobat Reader.

    RS MITRA KELUARGA
    Poli Umum

    Patient Registration Number (No. RM)

    Name

    First Name Last Name

    Email

    example@example.com

    Address

    Street Address

    Street Address Line 2

    City State / Province

    Postal / Zip Code

    Phone Number

    Please enter a valid phone number.

    1
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    Date

    Month Day Year

    Diagnosa
    Tuberculosis
    Pneumonia
    Asthma
    Falciparum malaria (malignant tertian)

    ICD 9

    ICD 10

    ICD 11

    Submit
    Submit

    2
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