PEMERINTAH KABUPATEN ACEH BARAT DAYA

PUSKESMAS MANGGENG

KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA

Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762

SURAT RUJUKAN PUSKESMAS

No. Rujukan
FKTP
Kabupaten

:
: Puskesmas Manggeng
: Aceh Barat Daya

Kepada Yth ;
TS,Poli dr

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

RSU

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

Mohon Pemeriksaan dan Penanganan lebih lanjut penderita :

Nama

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

No. Kartu BPJS

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

Tanggal Lahir / Umur

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

Jenis Kelamin

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

Alamat

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

Keluhan

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

Diagnosa Sementara : ...............................................................................................................................

Telah diberikan

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

Demikian atas kerja sama yang baik teman sejawat kami ucapkan terima kasih.
Yang menerima rujukan ;
Pada tanggal ,.......................

Manggeng,............................................
Salam Sejawat,

(...........................................................)
NIP./ NRPTT.........................................

( dr.HERY FAKHRIZAL )
NIP. 19860402 201412 2 1 002

PEMERINTAH KABUPATEN ACEH BARAT DAYA

PUSKESMAS MANGGENG

KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA

Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762

SURAT RUJUKAN PUSKESMAS

No. Rujukan
FKTP
Kabupaten

:
: Puskesmas Manggeng
: Aceh Barat Daya

Kepada Yth ;
TS,Poli dr

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

RSU

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

Mohon Pemeriksaan dan Penanganan lebih lanjut penderita :

Nama

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

No. Kartu BPJS

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

Tanggal Lahir / Umur

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

Jenis Kelamin

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

Alamat

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

Keluhan

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

Diagnosa Sementara : ...............................................................................................................................

Telah diberikan

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

Demikian atas kerja sama yang baik teman sejawat kami ucapkan terima kasih.

Yang menerima rujukan ;

Pada tanggal ,.......................

Manggeng,............................................
Salam Sejawat,

(...........................................................)
NIP./ NRPTT.........................................

( dr.HESSI ARFINA )
NIP. 19820320 200804 2 001

PEMERINTAH KABUPATEN ACEH BARAT DAYA

PUSKESMAS MANGGENG

KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA

Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762

SURAT KETERANGAN MEDIS

NAMA

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

NO. IDENTITAS

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

ALAMAT

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

KELUHAN

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

DIAGNOSA

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

THERAPY

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

MENERANGKAN KONDISI :
.................................................................................................................................................................................
.................................................................................................................................................................................

Manggeng,............................................
Dokter Yang Menangani

( dr.HESSI ARFINA )
NIP. 19820320 200804 2 001

PEMERINTAH KABUPATEN ACEH BARAT DAYA

PUSKESMAS MANGGENG

KECAMATAN MANGGENG KABUPATEN ACEH BARAT DAYA

Jalan Nasional nomor 107 Manggeng Telp (0659) 92178. Pos. 23762

SURAT KETERANGAN MEDIS

NAMA

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

NO. IDENTITAS

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

ALAMAT

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

KELUHAN

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

DIAGNOSA

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

THERAPY

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

MENERANGKAN KONDISI :
.................................................................................................................................................................................
.................................................................................................................................................................................

Manggeng,............................................
Dokter Yang Menangani

( dr.HERY FAKHRIZAL )
NIP. 19860402 201412 2 1 002