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