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RUMAH SAKIT AS-SYIFA

Jl. Gerak Alam RT. 13 Kelurahan Kota Medan


Kecamatan Kota Manna Kabupaten Bengkulu Selatan
Telp. (0739) 2188 Email : rs.assyifa.manna@gnail.com

Manna, 20
Kepada Yth,
Nomor : Ts ……………..........………………….
Sifat : Biasa …………………………..…………
Perihal : Pengiriman Pasien Di –
………………………………….

Dengan hormat,

Bersama ini kami kirimkan seorang penderita :

Nama : .....................................................................................
Umur/ jenis kelamin : .....................................................................................
Alamat : .....................................................................................
Nomor CM : .....................................................................................

Yang telah dirawat di Unit Rawat Jalan / Unit Rawat Inap / UPF ……………………………..
Rumah Sakit Umum Daerah Hasanuddin Damrah Manna selama ………………………. hari
dengan diagnosis ………………………………………………………………………………...
Telah kami berikan pengobatan / tindakan :

1. ..........................................................................................................................................
2. ..........................................................................................................................................
3. ..........................................................................................................................................
4. ..........................................................................................................................................
5. ..........................................................................................................................................
6. ..........................................................................................................................................
7. ..........................................................................................................................................

Penderita tersebut perlu / tidak perlu kontrol :


......................................................................................................................................................
Saran :
......................................................................................................................................................
......................................................................................................................................................

Demikianlah kami sampaikan, atas perhatiannya kami ucapkan terima kasih.

An. Direktur RS As-Syifa


Dokter yang merawat

dr. ................................................................
NIP.

Tindasan :
1. Arsip ....................................................