RUMAH SAKIT IBU DAN ANAK CICIK

Jl. Dr. sutomo No.94 Padang

Telp. (0751) 38846, Fax: (0751) 841286
Email Address: rsbcicik@gmail.com

PELAYANAN AMBULANS PESERTA JKN

Nama Peserta :

No SEP :

Diagnosa :

Alasan Dirujuk :

Tanggal dirujuk : ............................................ Jam : .................................................

Tanggal tiba di RS rujukan : ............................................ Jam : .................................................

Petugas RSIA Cicik, Petugas di RS Penerima, Keluarga Pasien,

( ................................ ) ( ..................................... ) ( ................................ )

Nama Petugas & Cap RS

 RUMAH SAKIT IBU DAN ANAK CICIK
Jl. Dr. sutomo No.94 Padang
Telp. (0751) 38846, Fax: (0751) 841286
Email Address: rsbcicik@gmail.com

SURAT RUJUKAN BAYI

Kepada
Yth. TS ...........................................................

TS. Yang terhormat,

Dengan ini kami kirimkan seorang bayi :
Nama : ................................................................................................
Umur : ...............................................................................................
Jenis Kelamin : P / L
Nama Orang Tua : ...............................................................................................
Ayah : ...............................................................................................
Ibu : ................................................................................................
Riwayat Persalinan : ................................................................................................
Lahir dengan : ................................................................................................
BBL : ................................................................................................
A/S : ................................................................................................
Kehamilan : Cukup / Tidak Cukup Bulan
Ketuban : ................................................................................................
Keluhan : ................................................................................................
Diagnosa : ................................................................................................
Terapi yang telah diberikan : ................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................................................................................
Kami mohon bantuannya untuk perawatan dan pengobatan selanjutnya. Atas bantuan dan
kerjasamanya kami ucapkan terima kasih.

Padang, ..............................20......
Pemeriksa

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