PEMERINTAH KABUPATEN PROBOLINGGO

DINAS KESEHATAN
PUSKESMAS RANUGEDANG
KECAMATAN TIRIS
Jl. Raya Pesawahan No. 01

SURAT PEMULANGAN
No. Regiter
Nama Pasien
Alamat
Pekerjaan
Dokter yang merawat
Diagnosis

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Obat pulang

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Diet Khusus
Aktifitas di rumah
Perawatan di Rumah

Umur/Kelamin
Tgl. Masuk
Tgl. Keluar
Tgl. Kontrol
Hari

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(L/P)
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Lampiran yang disertakan waktu pulang :

Hasil Laboratorium
Surat keterangan sakit
Alergi Obat
Lain-lain

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* Saya selaku pasien/keluarga pasien telah mendapatkan penjelasan tersebut diatas oleh petugas medis
Rawat Inap Puskesmas Ranugedang dan telah mengerti.
Pasien / Keluarga Pasien

Petugas

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Catatan :
Harap dibawa waktu kontrol