Surat Resep Kacamata Compress [PDF]

RUMAH SAKIT UMUM ADHYAKSA Jl.Hankam Raya No.60, Ceger, Jakarta Timur, Telp.021-29462345, Fax.021-29462370 Email :adhyaks

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RUMAH SAKIT UMUM ADHYAKSA Jl.Hankam Raya No.60, Ceger, Jakarta Timur, Telp.021-29462345, Fax.021-29462370 Email :[email protected] FORMULIR RESEP KACAMATA No. ……………./ RSUA / ………….. / 20 ……..

Progressive Bifocus Biasa Vitrum Vitrum Spher Cylndr

Axis

Prisma Vitrum Vitrum Basis Spher Cylndr

Axis

Prisma Forma Basis Vitror

Color Vitror

Distant Vitror

Pro login quitat Pro domo Pro Propin quitat

Nama

: ……………………………………

Umur

: ……………………………………

Jakarta, ……………………,20 …

( dr. …………………………………………. )