PEMERINTAH KABUPATEN CIREBON

DINAS KESEHATAN
UPT PUSKESMAS DTP PLUMBON
Jalan Raya Plumbon KM.12 Kecamatan Plumbon
Telp.( 0231 ) 321632 E-mail : puskesmasplumbon2@gmail.com
CIREBON
45155

Tanggal :...............................

Jam :...............................

INSTRUKSI RAWAT INAP

Nomor :.................................

Kepada Yth,

TS Dokter Jaga Perawatan

Di_

Puskesmas Plumbon

Mohon perawatan dan penanganan lebih lanjut pada penderita :

Nama :.......................................................................................... L / P

Umur :................................................................................... Thn / Bln

Alamat :..................................................................................................

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Pekerjaan :..................................................................................................

Nomor kartu Peserta :..................................................................................................

Diagnosa :..................................................................................................

Telah diberikan :..................................................................................................

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Demikian, atas bantuan dan kerjasamanya disampaikan terima kasih.

Pemeriksa,

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