Datang : Tanggal …………………………………………….

Jam…………………………………………………..
Nama Pasien : …………………………………………………………

1. Perawatan Perhari :………… ........... x Rp. 35.000 ... = Rp.………………………………

2. Dokter : ...................... x Rp. 20.000 ... = Rp. ................................

3. Askep : ...................... x Rp. 10.000 ... = Rp. .................................

4. BHP : ...................... x Rp. 15.000..... = Rp. .................................
5. Alkes : - Abocath : ...................... x Rp. 25.000 ...... = Rp. ................................

- Infus Set : ...................... x Rp. 25.000 ...... = Rp. ................................

- Cairan : ...................... x Rp. 20.000 ...... = Rp. ................................

- Catgut/Silk : ...................... x Rp. 10.000 .... = Rp. .................................

- Lidocain : ...................... x Rp. 5.000 ..... = Rp. .................................
6. Oksigen / Jam : ...................... xRp. 20.000 ....... = Rp. ................................

7. Tindakan : ...................... xRp. 20.000 ....... = Rp. ................................

8. Retribusi : ………………………………………………..
9. Laboratorium : ………………………………………………..
10.Lain-lain : ………………………………………………..

Kalibunder,……………………………………….. 2017
Sie ……………………….

………………………………………………
Datang : Tanggal …………………………………………….
Jam…………………………………………………..
Nama Pasien : …………………………………………………………

11.Perawatan Perhari :………… ........... x Rp. 35.000 ... = Rp.………………………………

12.Dokter : ...................... x Rp. 20.000 ... = Rp. ................................

13.Askep : ...................... x Rp. 10.000 ... = Rp. .................................

14.BHP : ...................... x Rp. 15.000 ..... = Rp. .................................
15.Alkes : - Abocath : ...................... x Rp. 25.000 ...... = Rp. ................................

- Infus Set : ...................... x Rp. 25.000 ...... = Rp. ................................

- Cairan : ...................... x Rp. 20.000 ...... = Rp. ................................

- Catgut/Silk : ...................... x Rp. 10.000 .... = Rp. .................................

- Lidocain : ...................... x Rp. 5.000 ..... = Rp. .................................
16.Oksigen / Jam : ...................... xRp. 20.000 ....... = Rp. ................................

17.Tindakan : ...................... xRp. 20.000 ....... = Rp. ................................

18.Retribusi : ………………………………………………..
19.Laboratorium : ………………………………………………..
20.Lain-lain : ………………………………………………..

Kalibunder,……………………………………….. 2017
Sie ……………………….

………………………………………………
No………………..
Telah terima dari ……………………………………………………………………………………………………………………...............................................
Uang Sejumlah
Untuk Pembayaran …………………………………..………………………………………………………………………………..........................................
……………………………………………………………………………….…………………………………….....................................................................................

Kalibunder, ……………………………………………… 2017

……………………………
Rp.

……………………………………………

No………………..
Telah terima dari ……………………………………………………………………………………………………………………...............................................
Uang Sejumlah
Untuk Pembayaran …………………………………..………………………………………………………………………………..........................................
……………………………………………………………………………….…………………………………….....................................................................................

Kalibunder, ……………………………………………… 2017

……………………………
Rp.

……………………………………………