PEMERINTAH KABUPATEN LANGKAT

DINAS KESEHATAN
UPT PUSKESMAS NAMO TERASI
DESA PASAR IV NAMO TERASI
Email Puskesmas : Pusk.namutrasi@gmail.com

Kepada YTH,
Bapak Ka. UPT Puskesmas Namo Terasi
Di
Tempat

LAPORAN DINAS

1. Dasar Penugasan :
2. Tujuan Kunjungan :
 Nama Pasien :
 Alamat :
 No. BPJS :
3. Hasil Kunjungan : ........................................................................................................
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4. Kesimpulan / Saran
Perbaikan : .......................................................................................................
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Namo Terasi, 2019

Tanda Tangan Pasien Ka.UPT Puskesmas Namo Terasi Petugas

(..................................) ( dr. Nirwana Ginting ) (.............................................)

NIP. 19711222200604 2020 NIP.