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DINAS KESEHATAN KABUPATEN TULANG BAWANG

UPT PUSKESMAS RAWA PITU


JL. Kanal Batang Hari RT 010 RK. 03 Kampung Batang Hari
Kecamatan Rawa Pitu Kabupaten Tulang Bawang Kode Pos 34596
Email : rawapitupuskesmas@gmail.com

BUKTI PELAYANAN AMBULANCE

Diberikan Kepada

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

Umur : .................................................................

No. Kartu BPJS Kes : .................................................................

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

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

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

No. Telp / HP : .................................................................

Diagnosa : .................................................................

Waktu Pelayanan : .................................................................

Menggala, ......................................... 2017

Petugas
Puskesmas Rawa Pitu

( ................................................. ) ( ................................................ )
Nip. Nip.
Keluarga Pasien

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