PUSKESMAS PULAU MANSINAM

Jalan Lingkar Pulau Mansinam

SURAT RUJUKAN
Tanggal : ........................................................................................

RS. : ........................................................................................

Yth. TS. Dokter Ahli : ........................................................................................

Mohon pemeriksaan / pengobatan lebih lanjut oleh terhadap penderita,

Nama Pasien Status Hubungan Keluarga : ........................................................................................

Nama peserta : ........................................................................................

KP. Akses : ........................................................................................

Anamanesia : ........................................................................................

Pemeriksaan Fisik : ........................................................................................

Diagnosa sementara : ........................................................................................

Obat yang telah diberikan : ........................................................................................

........................................................................................

Mengetahui,
Kepala Puskesmas

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Catatan :