No Nama Obat Satuan HJA@Rp

1 Acifar 400mg Tablet 1000

2 Acyclovir 400mg Tablet 1500
3 Acyclovir 200mg Tablet 1000
4 Acyclovir Zalf Tube 7000
5 Allopurinol 100mg Tablet 1000
6 Ambeven Tablet 2000
7 Ambroxol 30mg Tablet 1000
8 Amlodipin 10mg Tablet 2500
9 Amlodipin 5mg Tablet 2200
10 Amoxycillin 500mg Tablet 1000
11 Antalgin Tablet 1000
12 Antasida Tablet 1000
13 Arcapec Tablet 1800
14 Asam Mefenamat Tablet 1000
15 Asam Traneksamat 500mg Tablet 3500
16 Aspilet Tablet 1000
17 Benodon Inj. Vial 1300/ml
18 Betadine 30 ml Botol 26000
19 Betadine 5 ml Botol 5500
20 Captopril 25mg Tablet 1000
21 Caviplex Tablet 1000
22 Cefadroxil 500mg Tablet 1800
23 Cefadroxil syr Botol 13500
24 Cefixime syr Botol 41000
25 Cefixime 100mg Tablet 3600
26 Cetirizine Tab Tablet 1000
27 CTM Tablet 1000
28 Ciprofloxacin Tablet 1100
29 Combantrin Tablet 9000
30 Combivent Nebul 11000
31 Cortison Inj. Vial 4100/ml
32 Curcuma Sharppy Botol 16000
33 Cyclofem Vial 17500/vial
34 Demacolin Tablet 1200
35 Depopogrestin Vial 12500/vial
36 Dexametasone Inj. Ampul 4100/amp
37 Dololicobion Tablet 1000
38 Dulcolax Tablet 1000
39 Eflin Tablet 1700
40 Erlamycetin Eyedrop Botol 22000
41 Erlamycetin Eyezalf Tube 7000
42 Farsifen syr Botol 19000
43 Farsifen Tablet 1000
44 Fasidol drop Tablet 22000
45 Fasidol Syr Tablet 16000
46 Faxiden (Piroxicam) Tablet 1000
47 FG-Throces Tablet 1600
48 Flacoid (Dexamet) Tablet 1000
49 Flixotide Nebul 28000
50 Flumin Tablet 1000
51 Furosemide Tablet 1000
52 Gastrinal Tab Tablet 1000
53 Genoint Zalf Tube 5800
54 GG Tab Tablet 1000
55 Glibenclamid Tablet 1000
56 GOM Botol 4700
57 Grafalin 2mg Tablet 1000
58 Grafazol 500mg Tab Tablet 1000
59 Herbatia Sari ASI Tablet 3000
60 Histigo Tab Tablet 1000
61 Hydrocortison Zalf Tube 6000
62 Imboost Tablet 6000
63 Intunal Forte Tablet 1200
64 Intunal Syr Botol 19000
65 Intunal Tab Tablet 1000
66 Kaotin Syr Botol 16000
67 Kapsida Tablet 1400
68 Kemiderm Salep Tube 10500
69 Ketorolac 30 mg Inj Ampul 17500/amp
70 Lactacyd Baby Botol 39000
71 Lactacyd Wanita Botol 37000
72 Lacto-B Sachet 7500
73 Lapisiv Syr Botol 27500
74 Lapisiv Tab Tablet 1700
75 Lasal Expectorant Botol 42500
76 Laxadine Syr Botol 48000
77 Lerzin / Cetirizine syr Botol 19000
78 Licodexon Tablet 1000
79 Licokalk Tablet 1000
80 Licomet (Cimetidin) Tab Tablet 1000
81 Liconam (B6) Tab Tablet 1000
82 Licostan (AsMef) Tab Tablet 1000
83 Lidocain Inj Ampul 6000/amp
84 Licoprox Tablet 2400
85 Lopamid Tablet 1000
86 Loratadine Tablet 1000
87 Maltofer Tablet 5000
88 Maltofer syr Botol 100000
89 Mazol Salf Tube 3000
90 Mecobalamin 500mg Tab Tablet 1800
91 Meprotin syr Botol 24000
 92 Metformin 500 Tab Tablet 1000
93 Methergin Inj. Ampul 18000/amp
94 Methergin bos besar inj Ampul 15000/amp
95 Methyl Prednisolon 4 mg Tablet 1000
96 Metvell Ampul 10000/amp
97 Microlax Enema Enema 37000
98 Mucifat syr Botol 60000
99 Mucos drop Botol 40000
100 mucos syr Botol 27000
101 Neo Kaominal Syr Botol 15000
102 Neurotropic Inj. Vial 2500/ml
103 New Diatabs Tablet 1200
104 Nifedipin 10mg Tablet 1000
105 Nisagon Tube 6500
106 Norages Inj Ampul 15000/amp
107 Obimin Tablet 2500
108 Omegtrim 480mg Tablet 1000
109 Omeprazol Tablet 1000
110 Ondansetron 4mg Inj Ampul 12000/amp
111 Ondansetron 4mg Tablet 2500
112 Papaverin 40mg Tablet 1000
113 Phenylbutazon Tablet 1000
114 Piroxicam 20mg Tablet 1000
115 Potaflam 50mg Tablet 1000
116 Primavon 480mg Tablet 1000
117 Primperan drop Botol 300/tetes
118 Procet syr 120mg Botol 17000
119 Profolat Tablet 1000
120 Progesic syr 250mg Botol 32500
121 Pronalges Supp Suppo 26000
122 Propyretic Supp Suppo 9500
123 Pulmicort Nebul 18000
124 Pyrexin Supp Suppo 10000
125 Pyrexin Tablet 1000
126 Ranitidin Inj Ampul 7000/amp
127 Ranitidin Tablet 1000
128 Recodryl Inj. Vial 2000/ml
129 Sagestam inj. Ampul 12500/amp
130 Sangobion Tablet 1800
131 Scopma Plus Tablet 2100
132 Simvastatin 10mg Tablet 1000
133 Simvastatin 20mg Tablet 1000
134 Sintosinon Inj. Ampul 32000
135 Spasminal Tablet 1400
136 Sumagesic Tablet 1000
137 Teosal Tablet 1000
138 Thrombophob gel 10gr Tube 39000
139 Thrombophob gel 20gr Tube 59000
140 Thrombophob salep Tube 46000
141 Tiavit K inj Ampul 12500/amp
142 Triamcinolone Tablet 1200
143 Triclofem Inj. Ampul 17500/amp
144 Trifalgin Tablet 1000
145 Ventolin Nebul 18000
146 Vesperum 10 mg Tablet 1000
147 Vesperum syr Botol 17500
148 Vitamin B Complex Inj. Vial 2000/ml
149 Vitamin B12 Tablet 1000
150 Vitamin C Tablet 1000
151 Vitamin K Inj. Ampul 22500/amp
152 Vitamin K Tablet 10000
153 Vitonal F Tablet 10000
154 Yusimox Syr Tablet 14500
155 Yusimox Forte syr Botol 25000
156 Zetamol Tablet 1000
157 Zircum Kid syr Botol 37500
 HAMIL HAMIL
No. Reg : No. Reg :
No. BPJS : No. BPJS :
NIK : NIK :
Nama Ibu : Nama Ibu :
Nama Suami : Nama Suami :
Umur : Umur :
Alamat : Alamat :

No. Hp : No. Hp :
HPHT : HPHT :
HPL : HPL :
G P A AH G P A AH
LILA: BB: TB: GOLDA: LILA: BB: TB: GOLDA:
Riw. Penyakit : Riw. Penyakit :

SC : SC :
Alergi : Alergi :

HAMIL HAMIL
No. Reg : No. Reg :
No. BPJS : No. BPJS :
NIK : NIK :
Nama Ibu : Nama Ibu :
Nama Suami : Nama Suami :
Umur : Umur :
Alamat : Alamat :

No. Hp : No. Hp :
HPHT : HPHT :
HPL : HPL :
G P A AH G P A AH
LILA: BB: TB: GOLDA: LILA: BB: TB: GOLDA:
Riw. Penyakit : Riw. Penyakit :

SC : SC :
Alergi : Alergi :