GENERAL PRACTITIONER

dr. Dewa Made Krishna Medical Service:

phone : +628175792766 Family Doctor

email : krishnabayumurti@gmail.com Consultation
Complite Medicine
Call Out Service

RECEIPT NO :

Received With Thanks From : ................................................................................................................

Date of Birth : .................................................................................................................

Address : .................................................................................................................

In Settlement of Following Item

1. Doctor’s Fee :............................................................... Rp.................................

2. Medicine/Injection :............................................................... Rp..................................
3. Others :............................................................... Rp.................................
............................................................... Rp.................................

Rp............................

Diagnose: ................................ ........................... USD§

Therapy : 1. ............................ Tanjung, ......................., 20

2..............................

3..............................

4.............................

5............................. dr________________________

Attending Physician