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Jl. Raya Duri Kosambi Rt 012/02 No.

74
Duri Kosambi Cengkareng Jakarta Barat
(021) 541 0463
SURAT RUJUKAN
No. ........................................................
Jakarta, ..............................................
Kepada Yth. :
Dokter :
Rumah Sakit :
Mohon pemeriksaan / pengobatan lebih lanjut terhadap penderita :
NAMA : ...................................................................
UMUR : ................................................................... Jenis Kelamin : L / P
ALAMAT : ...................................................................
DIAGNOSA SEMESTARA : ....................................................................................................................
....................................................................................................................
DENGAN KETERANGAN SBB : ....................................................................................................................
....................................................................................................................
Keadaan Umum : Baik / Sedang / Buruk Terima Kasih
Kesadaran : CM / Delirium / Samnolent / Koma Salam Sejawat
T/D : N:
RR : S:
( ..................................................)