Format RESEP DOKTER Klinik Well

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Klinik Pratama Well Asta Medika Klinik Pratama Well Asta Medika Klinik Pratama Well Asta Medika

Jl. Mahakam Raya No. 16 Lingkar Barat, Bengkulu Jl. Mahakam Raya No. 16 Lingkar Barat, Bengkulu Jl. Mahakam Raya No. 16 Lingkar Barat, Bengkulu
Telp. (0736) 731364 Email : [email protected] Telp. (0736) 731364 Email : [email protected] Telp. (0736) 731364 Email : [email protected]

Dokter :.......................................................... Dokter :.......................................................... Dokter :..........................................................


SIP :.......................................................... SIP:.......................................................... SIP:..........................................................
Tgl :.......................................................... Tgl:.......................................................... Tgl:..........................................................
Poli :.......................................................... Poli :..........................................................
Poli :..........................................................
No. MR:.......................................................... No. MR:..........................................................
No. MR :..........................................................
Riwayat Alergi Obat Riwayat Alergi Obat Riwayat Alergi Obat
Tidak Tidak Tidak
Ya, Nama Obat....................... Ya, Nama Obat....................... Ya, Nama Obat.......................

R/ R/ R/

Nama :................................................... BB:........... Nama :................................................... BB:........... Nama :................................................... BB:...........


Tanggal Lahir: ....................................................... Tanggal Lahir: ....................................................... Tanggal Lahir: .......................................................
Alamat :................................................................... Alamat :................................................................... Alamat :...................................................................

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