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SURAT RUJUKAN

Yth. Dokter Gigi


:.............................................
Di RSU
:.............................................
Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita,
Nama Pasien
:...................................................
Jenis Kelamin
:....................................................
Umur
:....................................................
No. Telpon
:....................................................
Alamat Rumah
:....................................................
Anamnesa
a. Keluhan :
.......................................................................................................................................
.................................................................................................................
Diagnosa sementara : .................................................................................................
.................................................................................................
Kasus
:...................................................................................................
....................................................................................................
Terapi/Obat yang telah diberikan :
..........................................................................................
..........................................................................................
Demikian surat rujukan ini kami kirim, kami mohon balasan atas surat rujukan
ini. Atas perhatian Bapak/Ibu kami ucapkan terima kasih.

Hormat Kami

(..............................)
No. SIP:..................

Lembar 1 : Untuk Dokter Gigi dituju


Lembar 2 : Arsip Pengirim

JAWABAN RUJUKAN
Berikut ini adalah hasil pemeriksaan dan pengobatan atas pasien :
No. Registrasi
:....................................................
Nama Pasien
:....................................................
Jenis Kelamin
:....................................................
Umur
:....................................................
No. Telpon
:....................................................
Alamat Rumah
:....................................................

Keterangan tindak lanjut yang dianjurkan :


Konsul selesai
Perlu kontrol kembali (sebutkan)............................................
Perlu konsul ke ahli lain (sebutkan).......................................
Perlu dirawat dengan indikasi (sebutkan).............................
Hasil pemeriksaan :
.......................................................................................................................................
.......................................................................................................................................
Diagnosa :
Perawatan yang sudah dilakukan :
.......................................................................................................................................
.......................................................................................................................................

Demikian balasan surat rujukan ini kami kirim. Atas perhatian


Bapak/Ibu kami ucapkan terimaksih.
..........Tgl. .........
Hormat Kami,
(.....................)
NO.SIP : No. SIP: P1277665509

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