PEMERINTAH KABUPATEN KAYONG UTARA

DINAS KESEHATAN DAN KELUARGA BERENCANA

PUSKESMAS TELUK MELANO
Jalan : Merdeka Teluk Melano.Kode Pos 78853

SURAT RUJUKAN
No...................../PKM-TLM/201.......

Kepada
Yth.
..................................
di.
...................................

Menghadapkan pasien di bawah ini:

Nama :________________________ Tn / Ny / Nn*
Umur :______________Tahun / Bulan *
Alamat :____________________________________
____________________________________

Dengan hasil pemeriksaan sementara sebagai berikut :

Anamnesa : ____________________________________________
____________________________________________
Pemeriksaaan :____________________________________________
TD :.......................................................................................
Nadi :........................................................................................
Respirasi :........................................................................................
Suhu :........................................................................................
Therapi :........................................................................................
.........................................................................................
.........................................................................................
Diagnosa :........................................................................................

Leopold I :.......................................................................................
II :.......................................................................................
III :.......................................................................................
IV :......................................................................................
Periksa Dalam:......................................................................................

Mohon konsul dan penanganan lebih lanjut pasien diatas.Terima kasih.

Teluk Melano,..................................20...
Salam Sejawat,

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