Mohon kontrol selanjutnya penderita : Nama : ............................................................................................. Diagnosa : ............................................................................................. Terapi : ............................................................................................. Tindak lanjut yang dianjurkan Pengobatan dengan obat-obatan : Perlu rawat inap ....................................................................... Konsultasi selesai Kontrol kembali ke RS tanggal : .................... ........................ tgl .............................. Lain-lain : ...................................................... Dokter RS,