KLINIK LAURA MEDICA

Jalan Pelita V - Buntok Kalimantan Tengah Telp.0852-4681-0207

SURAT PENGANTAR PULANG

Nomor : ................... /KLM/................/20........
Kepada Yth;
...................................................
...................................................
Di ......................................
Bersamaan ini kami rujuk kembali seorang pasien, mohon diperiksa, pengobatan dan
perawatan pasien dimaksud adalah ;
Nama
: ..........................................................................................................L / P
TTL
: ............................./...................................................Umur : (..............) thn
Pekerjaan
: ........................................................................................................................
Alamat
: ........................................................................................................................
DIAGNOSIS
: ........................................................................................................................
Sudah duberikan : ........................................................................................................................
1 . .....................................................................................................................................................
2.
3.
Demikian Rujukan ini kami kirim, atas perhatian dan kerja sama yang baik kami ucapkan terimakasih
Buntok, ................................. 20........
Dokter yang memeriksa/merawat,

dr. ..................................................

KLINIK LAURA MEDICA

Jalan Pelita V - Buntok Kalimantan Tengah Telp.0852-4681-0207

SURAT PENGANTAR PULANG

Nomor : ................... /KLM/................/20........
Kepada Yth;
...................................................
...................................................
Di ......................................
Bersamaan ini kami rujuk kembali seorang pasien, mohon diperiksa, pengobatan dan
perawatan pasien dimaksud adalah ;
Nama
: ........................................................................................................... L / P
TTL
: ............................./...................................................Umur : (..............) thn
Pekerjaan
: ........................................................................................................................
Alamat
: ........................................................................................................................
DIAGNOSIS
: ........................................................................................................................
Sudah duberikan : ........................................................................................................................
1 . .....................................................................................................................................................
4.
5.
Demikian Rujukan ini kami kirim, atas perhatian dan kerja sama yang baik kami ucapkan terimakasih
Buntok, ................................. 20........
Dokter yang memeriksa/merawat,

dr. ..................................................