SURAT RUJUKAN PEMERIKSAAN KESEHATAN HAJI

Nomor :

Kepada Yth.
Sejawat Dokter Pemeriksa Kesehatan Lanjutan
RS .....................................................................

Dengan Ini Kami Kirimkan Jemaah haji

..................................................................................
Nama : .........................
..................................................................................
.........................
Umur : ..................Tahun
..................................................................................
Jenis Kelamin : .........................
..................................................................................
Alamat tinggal : .........................
...................................................................................
.........................
Kab/Kota ...............................................................
...................................................................................
Diagnosis : .........................
...................................................................................
..........................
Untuk dilakukan pemeriksaan dan penatalaksanaan lebih lanjut.
Terapi yang sudah diberikan ............................................................................................
........................................................................................................................................................................
........................................................................................................................................................................
........................................................................................................................................................................

Tasikmalaya ,........................20
Pemeriksa Kesehatan Dasar
UPT Puskesmas Singaparna

dr. Hj. Herlawati

NIP. 19690824 200212 2 003
 SURAT RUJUKAN BALIK PEMERIKSAAN KESEHATAN HAJI
Nomor :

Kepada Yth.
Sejawat Dokter Pemeriksa Kesehatan Dasar
RS .....................................................................

Dengan Ini Kami Kirimkan Jemaah haji

......................................................................................................
Nama : .....
......................................................................................................
.....
Umur : ..................Tahun
......................................................................................................
Jenis Kelamin : .....
......................................................................................................
Alamat tinggal : .....
.......................................................................................................
.....
Kab/Kota ...............................................................
.......................................................................................................
Diagnosis : .....
.......................................................................................................
......
Untuk dilakukan pemeriksaan dan penatalaksanaan lebih lanjut.
Terapi yang sudah diberikan ................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
Saran Terapi Selanjutnya .....................................................................................................
.........................................................................................................................................................................

Tasikmalaya ,........................20
Pemeriksa Kesehatan Lanjutan
RS ..................................................

NIP.
 DINAS KESEHATAN KABUPATEN TASIKMALAYA DINAS KESEHATAN KABUPATEN TASIKMALAYA
UPTD PUSKESMAS SINGAPARNA UPTD PUSKESMAS SINGAPARNA

SURAT KETERANGAN SEHAT SURAT KETERANGAN SEHAT

NO. / / / 2013 NO. / / / 2013

Yang bertanda tangan di bawah ini menerangkan bahwa : Yang bertanda tangan di bawah ini menerangkan bahwa :

Nama : ........................................................................................................ Nama : .............................................................................................................

Umur : ........................................................................................................
Jenis Kelamin : ........................................................................................................
Pekerjaan : ........................................................................................................
Alamat : ........................................................................................................
........................................................................................................
Umur : .............................................................................................................
Jenis Kelamin : .............................................................................................................
Pekerjaan : .............................................................................................................
Alamat : .............................................................................................................
.............................................................................................................

Menurut pemeriksaan kami orang tersebut diatas benar dalam keadaan sehat. Menurut pemeriksaan kami orang tersebut diatas benar dalam keadaan sehat.
Surat Keterangan ini diperlukan untuk ................................................................................ Surat Keterangan ini diperlukan untuk .........................................................................
Demikian surat Keterangan ini kami buat. Demikian surat Keterangan ini kami buat.

TB :................Cm Singaparna ,.............................2013 TB :................Cm Singaparna ,...................................2013

BB :................Kg Dokter yang memeriksa BB :................Kg Dokter yang memeriksa
TD :................MmHg TD :................MmHg

dr. H. Purnama Bahrum dr. H. Purnama Bahrum

NIP. 19560818 198512 1 001 NIP. 19560818 198512 1 001