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Desain TUKURAGI 2022

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TUKURAGI

(KARTU PENGINGAT KUNJUNGAN GIGI IBU HAMIL

UPT PUSKESMAS KEDUNGGALAR 2022

NAMA :..................................................................................

ALAMAT/ NO. HP :......................................................./..........................

MULAI PEMERIKSAAN :.................................................................................

USIA KEHAMILAN :.................................................................................

NO. BPJS :..................................................................................

Jadwal Kunjungan dan terapi Paraf

No. Elemen gigi setelah
senin selasa rabu kamis jumat sabtu tindakan
Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........
1.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

2.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

3.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

4.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

5.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

6.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

7.
Pro:........... Pro:........... Pro:........... Pro:........... Pro:........... Pro:...........

Penanggung jawab,

drg. Lussie Novita Anggraini

NIP. 199001142019032010

 Diberikan pada ibu hamil

TUKURAGI

(KARTU PENGINGAT KUNJUNGAN GIGI IBU HAMIL

UPT PUSKESMAS KEDUNGGALAR 2022

NAMA :..................................................................................

ALAMAT / NO. HP :......................................................./..........................

MULAI PEMERIKSAAN :.................................................................................

USIA KEHAMILAN :.................................................................................

NO. BPJS :..................................................................................

NO. ELEMEN GIGI DIAGNOSA JENIS JADWAL Paraf

TINDAKAN TERAPI setelah
KG tindakan

Penanggung jawab,

drg. Lussie Novita Anggraini

NIP. 199001142019032010

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Desain TUKURAGI 2022

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Desain TUKURAGI 2022

Uploaded by

Copyright:

Available Formats

TUKURAGI

(KARTU PENGINGAT KUNJUNGAN GIGI IBU HAMIL

UPT PUSKESMAS KEDUNGGALAR 2022

ALAMAT/ NO. HP :......................................................./..........................

MULAI PEMERIKSAAN :.................................................................................

USIA KEHAMILAN :.................................................................................

NO. BPJS :..................................................................................

Jadwal Kunjungan dan terapi Paraf

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:........... Tgl:...........

drg. Lussie Novita Anggraini

 Diberikan pada ibu hamil

(KARTU PENGINGAT KUNJUNGAN GIGI IBU HAMIL

UPT PUSKESMAS KEDUNGGALAR 2022

ALAMAT / NO. HP :......................................................./..........................

MULAI PEMERIKSAAN :.................................................................................

USIA KEHAMILAN :.................................................................................

NO. BPJS :..................................................................................

NO. ELEMEN GIGI DIAGNOSA JENIS JADWAL Paraf

drg. Lussie Novita Anggraini

 Dibawa oleh dokter gigi

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