SURAT RUJUKAN

(REFERRAL LETTER)
Kepada Yth:
Teman Sejawat/Dear Colleague,
dr.....................................................................
Di/At:................................................................

Dengan hormat,
With respected greetings,

Kami merujuk pasien dengan detail sebagai berikut/we refer this patient detailed in follow:
Nama/Name
Umur/Age
Jenis Kelamin/Sex
Warga negara/Nationality
Alamat/Address
No. RM (Medical Record No.)

: ..............................................................................................
: .....................................................................................................
: ...............................................................................................
: ...............................................................................................
: ...............................................................................................
: ...............................................................................................

Diagnosis kerja/Assesment

: ...................................................................................

Hasil penatalaksanaan yang telah dilakukan meliputi/Management so far:

Anamnesis/Anamnese
: .................................................................................
Pemeriksaan Fisik/Physical examination : .................................................................................
Pemeriksaan Penunjang/Supporting examination: .......................................................................
Terapi yang telah diberikan/Treatment so far: ..............................................................................
Keterangan lainnya/Other information
: .................................................................................
Mohon untuk/Kindly

: ...............................................................................................

Atas perhatian dan kerjasamanya kami ucapkan terima kasih / Thank you for your attention

Denpasar, ..................................................
Salam sejawat/Yours truly,

..................................................................