SURAT PENGANTAR OPNAME

DARI RAWAT JALAN

Tanggal

Nama
Nomor
Tanggal Lahir
Jenis Kelamin
Umur

Jam

:
:
:
:
:

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

Kepada
Yth,
Bagian
:
Mohon perawatan terhadap pasien atas nama tersebut di atas dengan
1. Keluhan
: ..........................................................................................................................................
2. Pemeriksaan
3. Konsultasi
: ..........................................................................................................................................
4. Intruksi
5. Diagnosis
: ..........................................................................................................................................
: ..........................................................................................................................................
: ..........................................................................................................................................
...........................................................
Dokter Pemeriksa,

(..................................................)
Nama & Tanda Tangan Dokter

SURAT PENGANTAR OPNAME

DARI RAWAT JALAN

Tanggal

Nama
Nomor
Tanggal Lahir
Jenis Kelamin
Umur

Jam

:
:
:
:
:

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

Kepada
Yth,
Bagian
:
Mohon perawatan terhadap pasien atas nama tersebut di atas dengan
1. Keluhan
: ..........................................................................................................................................
2. Pemeriksaan
3. Konsultasi
: ..........................................................................................................................................
4. Intruksi
5. Diagnosis
: ..........................................................................................................................................
: ..........................................................................................................................................
: ..........................................................................................................................................
...........................................................
Dokter Pemeriksa,

(..................................................)
Nama & Tanda Tangan Dokter