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Contoh surat Rujukan

Yth. Dokter Gigi


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Di RSU
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Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita,
Nama Pasien
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Jenis Kelamin
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Umur
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No. Telpon
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Alamat Rumah
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Anamnesa
a. Keluhan : .................................................................................................................................................
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Diagnosa sementara : .................................................................................................
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Kasus
:...................................................................................................
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Terapi/Obat yang telah diberikan : ..........................................................................................
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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