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KESEHATAN DAERAH MILITER VII / WIRABUANA

RUMAH SAKIT TK.II 07.05.01 PELAMONIA

RUJUKAN PASIEN
Kepada Yth : ......................................................
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Kami mengirimkan pasien untuk perawatan selanjutnya, dengan alasan :
Tempat tidur penuh
Sesuai permintaan pasien / keluarga
Fasilitas Tidak Tersedia
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Dokter yang dituju

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

Nama Pasien

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

Jenis kelamin : .....................................

Tanggal Lahir

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

No. RM

Alamat

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

Nama Pengantar / Keluarga Terdekat


No. Telepon / HP

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

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

Penanggung Jawab Biaya


Keluhan Utama

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

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

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

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Pemeriksaan Fisik

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

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Pemeriksaan Penunjang: .......................................................................................................................
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Diagnosis
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Terapi / Tindakan
: ......... .................................................................................................................
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Terima kasih atas kerjasamanya.

Makassar , ....................................
A.n. Kepala Rumah Sakit
Dokter yang merawat

( .......................................... )
Tanda tangan dan nama jelas