FORM CAP Jari Kaki BAYI [PDF]

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RUMAH SAKIT UTAMA HUSADA



FORM./RM.DOC



Jalan Manggar 134 Tegalsari – Ambulu Telp. (0336) – 881186, 881187



CAP TELAPAK KAKI BAYI RUANG KELAS



:



Nama Ibu Bayi



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



Alamat



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



Tanggal Lahir Bayi



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



Jam Lahir Bayi



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



Berat Badan Bayi



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



Panjang Bayi



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



Jenis Kelamin Bayi



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



Apgar Score



: .................................................................. CAP TELAPAK JARI KAKI BAYI ( Kanan dan Kiri )



KAKI KIRI



KAKI KANAN



Ambulu, ............................................... Dokter Penolong



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No. RM