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    Gigi Pembayaran Tindakan

    Uploaded by

    heni

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    Download as docx, pdf, or txt
    of 2

    PEMERINTAH KABUPATEN GROBOGAN PEMERINTAH KABUPATEN GROBOGAN

    DINAS KESEHATAN DINAS KESEHATAN


    PUSKESMAS PULOKULON II PUSKESMAS PULOKULON II
    Jl.Raya Danyang – Kuwu KM.12Sembungharjo Jl.Raya Danyang – Kuwu KM.12 Sembungharjo
    ====================================== ======================================

    Nama : Nama :
    Umur : Umur :
    Alamat : Alamat :

    BUKTI PEMBAYARAN TINDAKAN BUKTI PEMBAYARAN TINDAKAN


     Tindakan Medik Gigi  Tindakan Medik Gigi
    1.Penambalan sementara Rp ……………….. 1.Penambalan sementara Rp ………………..
    2.Penambalan Gigi Tetap Rp………………... 2.Penambalan Gigi Tetap Rp………………...
    3.Pencabutan Gigi Susu Rp……………….. 3.Pencabutan Gigi Susu Rp………………..
    4.Pencabutan GigiTetap Rp……………….. 4.Pencabutan GigiTetap Rp………………..
    5.Insisi Abses Rp……………….. 5.Insisi Abses Rp………………..
    6.Pencabutan Gigi Impaksi Rp ………………. 6.Pencabutan Gigi Impaksi Rp ……………….
    7.Pembersihan Karang Gigi Rp ……………..... 7.Pembersihan Karang Gigi Rp …………….....
    =============================== ===============================
    Jumlah Rp ……………… Jumlah Rp ………………

    Bendahara Bendahara

    ……………………. …………………….

    PEMERINTAH KABUPATEN GROBOGAN PEMERINTAH KABUPATEN GROBOGAN


    DINAS KESEHATAN DINAS KESEHATAN
    PUSKESMAS PULOKULON II PUSKESMAS PULOKULON II
    Jl.Raya Danyang – Kuwu KM.12Sembungharjo Jl.Raya Danyang – Kuwu KM.12 Sembungharjo
    ====================================== ======================================

    Nama : Nama :
    Umur : Umur :
    Alamat : Alamat :

    BUKTI PEMBAYARAN TINDAKAN BUKTI PEMBAYARAN TINDAKAN


     Tindakan Medik Gigi  Tindakan Medik Gigi
    1.Penambalan sementara Rp ……………….. 1.Penambalan sementara Rp ………………..
    2.Penambalan Gigi Tetap Rp………………... 2.Penambalan Gigi Tetap Rp………………...
    3.Pencabutan Gigi Susu Rp……………….. 3.Pencabutan Gigi Susu Rp………………..
    4.Pencabutan GigiTetap Rp……………….. 4.Pencabutan GigiTetap Rp………………..
    5.Insisi Abses Rp……………….. 5.Insisi Abses Rp………………..
    6.Pencabutan Gigi Impaksi Rp ………………. 6.Pencabutan Gigi Impaksi Rp ……………….
    7.Pembersihan Karang Gigi Rp ……………..... 7.Pembersihan Karang Gigi Rp …………….....
    =============================== ===============================
    Jumlah Rp ……………… Jumlah Rp ………………

    Bendahara Bendahara

    ……………………. …………………….

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