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FORMULIR PENDAFTARAN PASIEN
PUSKESMAS KEBUN SIKOLOS
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NAMA PASIEN
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JENIS KELAMIN
PRIA
WANITA
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NO BPJS / NIK
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NO REKAM MEDIS/ NO KARTU BEROBAT
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JIKA BELUM MEMPUNYAI NOMOR REKAM MEDIS BISA ISI DENGAN ANGKA NOL
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ALAMAT
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NO HP
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PELAYANAN / POLI YANG DITUJU
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PELAYANAN UMUM
PELAYANAN KIA dan KB (IBU HAMIL & CATIN )
PELAYANAN GIGI DAN MULUT
PELAYANAN LABORATURIUM
PELAYANAN IMUNISASI
PELAYANAN ANAK
PELAYANAN PANDU PTM
PELAYANAN KONSULTASI , GIZI, OBAT , KESLING, PKPR
PELAYANAN TOTOK PUNGGUNG (TOPUNG)
RUANG TINDAKAN / P3K
TANGGAL KUNJUNGAN
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JAM PELAYANAN : SENIN-KAMIS JAM 08.00-11.00 dan JUMAT-SABTU JAM 08.00-10.00
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