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PEMERINTAH KABUPATEN SUMBAWA

KEPALA UNIT PELAKSANA TEKNIS PUSKESMAS UNIT I


KECAMATAN SUMBAWA

SURAT RUJUKAN

No. Rujukan : / / /

Puskesmas : Unit I Sumbawa

Kabupaten : Sumbawa

Kepada Yth. TS dr.poli :..............................................................

di :..............................................................

Mohon pemeriksaan dan penanganan lebih lanjut penderita

Nama :...............................................................

Umur :...............................................................

Alamat :...............................................................

Anamnesa
I. Keluhan utama :..........................................................................
..........................................................................

II. Riwayat perjalanan penyakit :...........................................................................

Pemeriksaan fisik
Keadaan umum :............................................................................
Vital sign
Tekanan darah :............................................................................
Nadi :............................................................................
Suhu :............................................................................
Respirasi :............................................................................

Telah di berikan :.....................................................................................

Diagnosa :.....................................................................................

Demikian atas bantuannya, di ucapkan banyak terima kasih

Salam sejawat

sumbawa,

dokter umum

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