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    2. IDENTITAS PASIEN.docx

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    22 views1 page

    Identitas Pasien

    Uploaded by

    heja

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    RM 1

    IDENTITAS PASIEN

    Nama Lengkap Pasien : ........................................................................................................

    NIK : ........................................................................................................

    Nama KK : ........................................................................................................

    Tempat/Tanggal Lahir : .........................................................................................................

    Jenis Kelamin :  Laki-laki  Perempuan

    Alamat : .........................................................................................................

    .........................................................................................................

    Pendidikan :  SD  SMP  SMA  Akademi  Sarjana

    Lainnya ................

    Pekerjaan : ........................................................................................................

    Agama :  Islam  Katolik  Protestan  Hindu  Budha

    Lainnya ...............

    No. Telp/ Hp : ........................................................................................................

    Jaminan Kesehatan :  Umum  BPJS  KIS  Lainnya ..................

    No : .............................................................................................

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