Form Pengantar Rawat Inap

FORM PENGANTAR

RS.HARAPAN BUNDA JL. T.UMAR No.181-211 BANDA ACEH

RAWAT INAP

 NAMA

: ............................................................................................. ...................................................... .......................................

UMUR

: ...................................................... ............................................................................................. .......................................

JENIS KELAMIN

: ...................................................... ............................................................................................. .......................................

 NO. REKAM MEDIS

: ............................................................................................ ...................................................... ......................................

MASUK MELALUI

:

DIAGNOSIS SEMENTARA

: ...................................................... ............................................................................................ ......................................

RUANGAN

: ...................................................... ............................................................................................ ......................................

PEMBIAYAAN/ASURANSI

: ...................................................... ............................................................................................ ......................................

PETUGAS PEMESAN KAMAR

: ...................................................... ............................................................................................ ......................................

KONFIRMASI PEMESAN KAMAR

: ..................................................... ............................................................................................ .......................................

KETERANGAN

: ...................................................... ............................................................................................ ......................................

IGD

Rujukan

Pengantar RI

Petugas Administrasi

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Poliklinik Spesialis

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FORM PENGANTAR

RS.HARAPAN BUNDA JL. T.UMAR No.181-211 BANDA ACEH

RAWAT INAP

 NAMA

: ............................................................................................. ...................................................... .......................................

UMUR

: ...................................................... ............................................................................................. .......................................

JENIS KELAMIN

: ...................................................... ............................................................................................. .......................................

 NO. REKAM MEDIS

: ............................................................................................ ...................................................... ......................................

MASUK MELALUI

:

DIAGNOSIS SEMENTARA

: ...................................................... ............................................................................................ ......................................

RUANGAN

: ...................................................... ............................................................................................ ......................................

PEMBIAYAAN/ASURANSI

: ...................................................... ............................................................................................ ......................................

PETUGAS PEMESAN KAMAR

: ...................................................... ............................................................................................ ......................................

KONFIRMASI PEMESAN KAMAR

: ..................................................... ............................................................................................ .......................................

KETERANGAN

: ...................................................... ............................................................................................ ......................................

IGD

Rujukan

Pengantar RI

Petugas Administrasi

(

Poliklinik Spesialis

Dokter Pengirim

)

(

)