Catatan Perpindahan Pasien
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Transcript of Catatan Perpindahan Pasien
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UNIVERSITAS AIRLANGGA RUMAH SAKIT
Kampus C Mulyorejo Surabaya 60115, Telp. 031-5916291, fax. 031-5916291 Email: [email protected], website: www.rumahsakit.unair.ac.id
LEMBAR IDENTITAS
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1. NAMA LENGKAP PASIEN : ............................................................................................................
2. JENIS KELAMIN : Laki-laki Perempuan / Umur : ....................................
3. TEMPAT/TGL. LAHIR : ......................................../.......................................................................
ALAMAT DOMISILI : Jalan : .........................................................................................
Desa : .........................................................................................
Kecamatan : .........................................................................................
Kabupaten/Kota : .........................................................................................
Provinsi : .........................................................................................
4. NO. TELP/HP : ...............................................................................................................
5. NO. KTP : ...............................................................................................................
6. STATUS PERNIKAHAN : Menikah Belum menikah Janda Duda
7. AGAMA : ...............................................................................................................
8. PENDIDIKAN : ...............................................................................................................
9. PEKERJAAN : ...............................................................................................................
10. NAMA AYAH/IBU/SUAMI/ISTRI* : ..................................................................................................
Pekerjaan : ...............................................................................................................
Alamat : ...............................................................................................................
No. Telp : ...............................................................................................................
11. NAMA KELUARGA/KENALAN DI SURABAYA : ............................................................................
Alamat : ...............................................................................................................
No. Telp : ...............................................................................................................
12. NAMA PENANGGUNG BIAYA : ......................................................................................................
No. ASKES / ASURANSI : ........................................................................................
Alamat : ........................................................................................
No. Telp : ........................................................................................
No RM :
