Keterangan ( diisi oleh konsulen atau dokter yang menerima rujukan )
Nama penderita :........................................................................... Umur :........................................................................... Alamat :........................................................................... Pekerjaan :........................................................................... Diagnosis :........................................................................... Therapi :........................................................................... ............................................................................ ............................................................................ Dokter yang menerima rujukan
(........................................)
1. Perlu kontrol kembali :..........................................
2. Perlu konsultasi ahli lain :.......................................... 3. Konsultasi selesai :..........................................
Lembar ini dikembalikan kepada pengirim setiap kali selesai konsultasi