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PT NUSANTARA SEBELAS MEDIKA

RUMAH SAKIT WONOLANGAN PROBOLINGGO


Jl. Raya Dringu No. 118 Telp. 0335 - 424007 Fax. 0335 - 431 937 Probolinggo

SURAT PENGANTAR MASUK RAWAT INAP

Nama Pasien : .................................. Ruang : ..............................


No Rekam Medis : .................................. Nama Keluarga Dekat : ..............................
Tanggal Lahir : .................................. Umur Keluarga : ..............................
Tanggal Masuk : .................................. Pekerjaan Keluarga : ..............................
Jam : .................................. No Tlp/HP : ..............................
Penjamin : .................................. Alamat Keluarga : ..............................
DPJP : .................................. ..............................
Diagnosa Masuk : .................................. ..............................
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Kelas : ..................................

Dokter Jaga

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Probolinggo

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