KLINIK UTAMA “ RIZKY AMALIA”

Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen

Telp. (0271) 8823814, Fax (0271) 882313

SURAT KETERANGAN PASIEN RAWAT JALAN

Menerangkan Bahwa :

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

Nomor RM : .......................................................................................

Nomor BPJS : .......................................................................................

Tanggal Lahir/Umur : ....................................................................................... L/P

Alamat : ...........................................................................................................................................

Diagnosa : ...........................................................................................................................................

Masih di lakukan pengobatan lanjutan di poliklinik ......................................... di Klinik Utama “RIZKY AMALIA”

Surat keterangan ini berlaku untuk 1 bulan pelayanan.

Demikian untuk menjadikan periksa.

Sragen, .......................................

(..................................................)
Tanda tangan dan nama dokter

KLINIK UTAMA “ RIZKY AMALIA”

Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen
Telp. (0271) 8823814, Fax (0271) 882313

SURAT KETERANGAN PASIEN RAWAT JALAN

Menerangkan Bahwa :

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

Nomor RM : .......................................................................................

Nomor BPJS : .......................................................................................

Tanggal Lahir/Umur : ....................................................................................... L/P

Alamat : ...........................................................................................................................................

Diagnosa : ...........................................................................................................................................

Masih di lakukan pengobatan lanjutan di poliklinik ......................................... di Klinik Utama “RIZKY AMALIA”

Surat keterangan ini berlaku untuk 1 bulan pelayanan.

Demikian untuk menjadikan periksa.

Sragen, .......................................

(..................................................)
Tanda tangan dan nama dokter
 KLINIK UTAMA “ RIZKY AMALIA”
Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen
Telp. (0271) 8823814, Fax (0271) 882313

PEMERIKSAAN ULTRASONOGRAFI
Nama :..................................................Umur:...............th IRNA/IRJA.....................................................

Alamat :..........................................................................................................................................................

No. Reg :..........................................................................................................................................................

No. BPJS :..........................................................................................................................................................

Hasil :.........................................................................................................................................................

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

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

Kesimpulan : .........................................................................................................................................................

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

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

Sragen,..............................201.............

Dokter yang memeriksa

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

KLINIK UTAMA “ RIZKY AMALIA”

Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen
Telp. (0271) 8823814, Fax (0271) 882313

PEMERIKSAAN ULTRASONOGRAFI
Nama :..................................................Umur:...............th IRNA/IRJA.....................................................

Alamat :..........................................................................................................................................................

No. Reg :............................................................................................................................................................

No. BPJS :..........................................................................................................................................................

Hasil :..........................................................................................................................................................

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

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

Kesimpulan : .........................................................................................................................................................

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

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

Sragen,..............................201.............

Dokter yang memeriksa

.............................................................
 KLINIK UTAMA “ RIZKY AMALIA”
Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen
Telp. (0271) 8823814, Fax (0271) 882313

INSTALASI GAWAT DARURAT / POLIKLINIK .......................................................................................

SURAT PERINTAH RAWAT INAP

Kepada Yth,

Tempat Pendaftaran Pasien Rawat Inap (TPPRI)

Di Tempat

Mohon didaftarkan sebagai pasien rawat inap terhadap :

Nama : ....................................................................................... Nomor Rm :..................................

Tanggal lahir : ................................................................ L /P

Diagnosis : .............................................................................................................................................

Dokter yang merawat : .............................................................................................................................................

Dokter pengirim : .............................................................................................................................................

Terapi : .............................................................................................................................................

Pasien memerlukan kamar perawatan :

Biasa Isolasi ICU NICU PICU

Atas perhatiannya saya ucapkan terima kasih.

Sragen, ..................................................

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

Tanda tangan dan nama dokter

KLINIK UTAMA “ RIZKY AMALIA”

Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen
Telp. (0271) 8823814, Fax (0271) 882313

INSTALASI GAWAT DARURAT / POLIKLINIK .......................................................................................

SURAT PERINTAH RAWAT INAP

Kepada Yth,

Tempat Pendaftaran Pasien Rawat Inap (TPPRI)

Di Tempat

Mohon didaftarkan sebagai pasien rawat inap terhadap :

Nama : ....................................................................................... Nomor Rm :..................................

Tanggal lahir : ................................................................ L /P

Diagnosis : .............................................................................................................................................

Dokter yang merawat : .............................................................................................................................................

Dokter pengirim : .............................................................................................................................................

Terapi : .............................................................................................................................................

Pasien memerlukan kamar perawatan :

Biasa Isolasi ICU NICU PICU

Atas perhatiannya saya ucapkan terima kasih.

Sragen, ..................................................
 KLINIK UTAMA “ RIZKY AMALIA”
Alamat : Jl. Ahmad Yani No. 100, Cantet Wetan, Sragen
Telp. (0271) 8823814, Fax (0271) 882313

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

Tanda tangan dan nama dokter