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DINAS KESEHATAN KABUPATEN SARMI

PUSKESMAS SAMANENTE
Alamat: Distrik Tor Atas-(Seser)-Email:pkm_smnt@yahoo.com (Papua)

SURAT RUJUKAN
No. 843/030/pkm-smnt/iii/2018

Kepada Yth
.................................................................
.................................................................
di-
.................................

Mohon pemeriksaan dan penanganan lebih lanjut terhadap pasien;

Nama :................................................................................................
Umur :................................................................................................

Jenis Kelamin :................................................................................................

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

Anamnesa :................................................................................................

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

..................................................................................................
TD :.................................mmHg
Fisik :.................................................................................................
...................................................................................................

Therapi :..................................................................................................
...................................................................................................
Diagnosa :..................................................................................................

Demikian surat rujukan ini kami buat atas kerjasamnya kami ucapkan terimakasih.

Samanente,.........................................
Pengirim

............................................................
Nip/Nrptt.
DINAS KESEHATAN KABUPATEN SARMI
PUSKESMAS SAMANENTE
Alamat: Distrik Tor Atas(Seser) E-mail:pkm_smnt@yahoo.com (Papua)

SURAT PENGANTAR
No. 445/030/pkm-smnt/iii/ 2018

Kepada Yth
.................................................................
.................................................................
di-
.................................

Mohon pemeriksaan dan penanganan lebih lanjut terhadap pasien;

Nama :................................................................................................
Umur :................................................................................................

Jenis Kelamin :................................................................................................

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

Anamnesa :................................................................................................

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

..................................................................................................
TD :.................................mmHg
Fisik :.................................................................................................
...................................................................................................

Therapi :..................................................................................................
...................................................................................................
Diagnosa :..................................................................................................

Demikian surat pengantar ini kami buat atas kerjasamnya kami ucapkan terimakasih.

Samanente,.........................................
Pengirim

............................................................
Nip/Nrptt.

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