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SURAT KETERANGAN GAWAT DARURAT

Yang bertanda tangan di bawah ini :


Nama : ...................................................................................................................
Rumah Sakit : WIJAYA KUSUMAH

Menerangkan bahwa telah dilakukan pemeriksaan dan perawatan terhadap pasien :

Nama Pasien : ...................................................................................................................


Jenis Kelamin : ...................................................................................................................
Umur : …………… tahun
Alamat : ...................................................................................................................
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Tanggal Pemeriksaan : ...................................................................................................................

Anamnesa :
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Diagnosa saat masuk RS :


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Kategori
Gawat Darurat / Gawat Tidak Darurat / Darurat Tidak Gawat / Tidak Gawat Tidak Darurat
(*pilih salah satu)

Demikian surat keterangan ini dibuat untuk dapat dipergunakan sebagaimana mestinya.

Kuningan , …… ………………………20 …
Dokter pemeriksa,

( …………………………………………………… )

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