x

DINAS KESEHATAN KABUPATEN KARAWANG

PUSKESMAS: RAWAMERTA
TgL..................................
SURAT RUJUKAN
No :
/ PKM /

/2016

Kepada
Yth,

Dengan hormat,

TS

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

RS : ..................................

Mohon Konsul/pemeriksa/Pengobatanlebih lanjut terhadap Penderita :

Nama Penderita
Umur
Alamat

: .................................................................................................
: .................................hr/bulan/tahun...........L/P
: Kp ..................................................................... Desa: .......................................................
.............................................................................................................................................
Kecamatan : .......................................................................................................................

Anamnese
: .............................................................................................................................
Diagnosa Sementa
: .............................................................................................................................
Obat Yang Sudah diberikan
: ...........................................................................................................................
Terima kasih
: ............................................................................................................................

Salam sejawat

dr.Sutardi
NRPTT:873.32.14.11.1.
0413
Jawaban Rujukan
Konsul Selesai/Perlu Kontrol Kembali
Konsul Sesuai/Perlu kontrol Kembali
Perlu Konsul ke Ahli Lain (Sebutkan)
: ............................................................................................................................
Peerlu Tindakan Medis Lain (Sebutkan)
: ............................................................................................................................
Perlu dirawat dengan Indikasi (Sebutkan) :
l..................................................................................................................................
Diagnose
........
Terapi Yang Diberikan
Anjuran
Tanggal Dan Catatan

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

Untuk dikembalikan Pada Dokter Pengirim Setelah Selesai

Berlku 1 Bulan Untuk Penyakit Keras

Salam sejawat

( ..................................
......)

DINAS KESEHATAN KABUPATEN KARAWANG

PUSKESMAS: RAWAMERTA
TgL..................................
SURAT

RUJUKAN
No:
/PKM/

/ 2016

Kepada
Yth,

Dengan hormat,

Ts ...........................
RS : ................................
Mohon Konsul/pemeriksa/Pengobatan lebih lanjut terhadap Penderita :
Nama Penderita
Umur
Alamat

: .................................................................................................
: .................................hr/bulan/tahun............L/P
: Kp ..................................................................... Desa: .......................................................
.............................................................................................................................................
Kecamatan : .......................................................................................................................

Anamnese
: .............................................................................................................................
Diagnosa Sementa
: .............................................................................................................................
Obat Yang Sudah diberikan
: ...........................................................................................................................
Terima kasih
: ............................................................................................................................

Salam sejawat

dr.Eneng Sukmayanti
NIP:
197703082014122001
Jawaban Rujukan
Konsul Selesai/Perlu Kontrol Kembali
Konsul Sesuai/Perlu kontrol Kembali
Perlu Konsul ke Ahli Lain (Sebutkan)
: .............................................................................................................................
Peerlu Tindakan Medis Lain
(Sebutkan)
: .............................................................................................................................
Perlu dirawat dengan Indikasi
(Sebutkan) : .............................................................................................................................

Diagnose
........
Terapi Yang Diberikan

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

Anjuran
Tanggal Dan Catatan

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

Untuk dikembalikan Pada Dokter Pengirim Setelah Selesai

Berlku 1 Bulan Untuk Penyakit Keras

Salam sejawat

( ..................................
......)