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Contoh 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 : .................................................................................................
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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

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