Anda di halaman 1dari 2

PEMERINTAH PROVINSI SULAWESI SELATAN

RUMAH SAKIT KHUSUS DAERAH


Jl: Lanto Dg. Pasewang No. 34 Telepon: (0411) 873120
Fax: (0411) 872167 E-mail: rsdadiss@plasa.com
M a k a s s a r 90131

RUJUKAN PASIEN
Kepada Yth : ...................................................... ...........................................................
Kami mengirimkan pasien untuk perawatan selanjutnya, dengan alasan :
Tempat tidur penuh
Sesuai permintaan pasien / keluarga
Fasilitas Tidak Tersedia
..............................................................

Dokter yang dituju : ...............................................................................................


Nama Pasien : .......................................
Jenis kelamin : .....................................
Tanggal Lahir : .......................................
No. RM : .....................................
Alamat : ............................................................................................................................

Nama Pengantar / Keluarga Terdekat :..............................................................................


No. Telepon/ HP : …………………………................................................................
Penanggung Jawab Biaya : .....................…………………………………………………..

Keluhan
Utama : ................................................................................................................................................
..............................................................................................................................................................
................................................................................................

Pemeriksaan
Fisik : ...................................................................................................................................................
...............................................................................
……………………………………………………………………………………………………......
........…….

Pemeriksaan Penunjang
:.............................................................................................................................................................
..............................................................................................................................................................
..............................................................................................
Diagnosis
:.............................................................................................................................................................
...........................................................................................................
Terapi / Tindakan :
................................................................................................................. ............................................
..............................................................................................................................................................
..........................................................................................
Terima kasih atas kerjasamanya.

Makassar , ....................................
A.n. Kepala Rumah Sakit
Dokter yang merawat

( .......................................... )
Tanda tangan dan nama jelas

Anda mungkin juga menyukai