N0 : ................... KARTU IMUNISASI

(Long Life Card)

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*) Coret yang tidak perluNo : ........................

KARTU IMUNISASI

(Long Life Card)

Nama Bayi / Anak :............................................................................................

Tempat / Tanggal Lahir :............................................................................................

Jenis Kelamin :............................................................................................

Nama Ibu :............................................................................................

Nama Kepala Keluarga :............................................................................................

Alamat :

Jalan :............................................................................................

RT / RW :............................................................................................

Desa/ Kelurahan :............................................................................................

Kecamatan :............................................................................................

Dati II :............................................................................................

Wilayah Puskesmas :............................................................................................

Tanda Tangan / Cap

( ) Nip :

*) Coret yang tidak perlu