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No. Tanggal Nama Pasien Alamat Diagnosa

K

L P B

1 2 3 4 ! " # $ 1% 11 1

Nomo&In'e(Ka&tu

)mu&Ta*un

 JenisKelamin Nama Ke+ala

Kelua&gaKo'e

Pen,a(it

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Pengo-atan Tin'a(an )m A( Ket

1 1! 1" 1# 1$

)K/LP

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