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PEMERINTAH KABUPATEN LANGKAT DINAS KESEHATAN

UPT PUSKESMAS NAMO TERASI DESA PASAR IV NAMO TERASI Email Puskesmas : Pusk

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PEMERINTAH KABUPATEN LANGKAT DINAS KESEHATAN

UPT PUSKESMAS NAMO TERASI DESA PASAR IV NAMO TERASI Email Puskesmas : [email protected]

Kepada YTH, Bapak Ka. UPT Puskesmas Namo Terasi Di Tempat LAPORAN DINAS 1. Dasar Penugasan : 2. Tujuan Kunjungan : 

Nama Pasien

:



Alamat

:



No. BPJS

:

3. Hasil Kunjungan

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

4. Kesimpulan / Saran Perbaikan

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

Namo Terasi, Tanda Tangan Pasien

(..................................)

2019

Ka.UPT Puskesmas Namo Terasi

Petugas

( dr. Nirwana Ginting )

(.............................................)

NIP. 19711222200604 2020

NIP.