Anda di halaman 1dari 1

Dokter Perusahaan

dr. Muhammad Aji Imaduddin


SIP.

Yth. Dokter :.............................................


Di RSU :.............................................

Mohon pemeriksaan dan pengobatan lebih lanjut terhadap pasien,

Nama :...................................................
Jenis Kelamin :....................................................
Umur :....................................................
Alamat Rumah :....................................................

Anamnesa
............................................................................................................................................................
............................................................................................................................................................

Pemeriksaan
............................................................................................................................................................
............................................................................................................................................................

Diagnosa sementara
............................................................................................................................................................
...........................................................................................................................................................

Terapi/Obat yang telah diberikan :


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

Atas kerjasama bapak/ibu, kami ucapkan terimakasih.

Hormat Kami

(..............................)
No.SIP:..................

Anda mungkin juga menyukai