RUMAH SAKIT RUMAH SAKIT RUMAH SAKIT

Jl. Lintas Sumatera No. 12 Kalibalangan-Lampung Utara Jl. Lintas Sumatera No. 12 Kalibalangan-Lampung Utara Jl. Lintas Sumatera No. 12 Kalibalangan-Lampung Utara
Phone : (0724) 3260237 Email: rs.hmy2011@gmail.com Phone : (0724) 3260237 Email: rs.hmy2011@gmail.com Phone : (0724) 3260237 Email: rs.hmy2011@gmail.com

SURAT RUJUKAN BALIK SURAT RUJUKAN BALIK SURAT RUJUKAN BALIK

Tenam Sejawat Yth, Tenam Sejawat Yth, Tenam Sejawat Yth,

Mohon Kontrol Selanjutnya Penderita Mohon Kontrol Selanjutnya Penderita Mohon Kontrol Selanjutnya Penderita

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

Diaknosa :.............................................. Diaknosa :.............................................. Diaknosa :..............................................

Tindak Lanjut di anjurkan : Tindak Lanjut di anjurkan : Tindak Lanjut di anjurkan :

Pengobatan dengan obat-obatan : Pengobatan dengan obat-obatan : Pengobatan dengan obat-obatan :

1. ........................................................... 5. ........................................................... 9. ...........................................................

2. ........................................................... 6. ........................................................... 10. ...........................................................
3. ........................................................... 7. ........................................................... 11. ...........................................................
4. ........................................................... 8. ........................................................... 12. ...........................................................

Perlu Rawat Inap Perlu Rawat Inap Perlu Rawat Inap

Konsultasi Selesai Konsultasi Selesai Konsultasi Selesai

Kontrol Kembali ke RS Tanggal :..................................... Kontrol Kembali ke RS Tanggal :..................................... Kontrol Kembali ke RS Tanggal :.....................................

Lain-lain :........................................................................ Lain-lain :........................................................................ Lain-lain :........................................................................

Kalibalangan,.........................20 Kalibalangan,.........................20 Kalibalangan,.........................20

Dokter RS Dokter RS Dokter RS

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