LEMBAR REKAM MEDIK GIGI STOVIT GOES TO SCHOOL AND SOCIETY

FAKULTAS KEDOKTERAN GIGI - UNIVERSITAS AIRLANGGA

Jl. Prof Dr. Moestopo No. 47 – Surabaya

NAMA :

USIA : ( L / P ) | TENSI :

ALAMAT :

NO. HP / TELP. :

RWYT PENYAKIT :

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

8 7 6 5 4 3 2 1 1 2 3 4 5 6 7 8

V IV III II I I II III IV V

V IV III II I I II III IV V

Pilih Perawatan Yang Dilakukan :

Konservasi Bedah Mulut Prostodonsia

Penyakit Mulut Orthodonsia

Periodonsia Pedodonsia

Diagnosa Perawatan :

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OPERATOR (ISI NAMA & NIM) :

NO. REGISTRASI : - - -