Klinik

BSD

JL Raya Serpong Sektor VII, Bolk RP No 92 BSD

Telp./Fax. 021 5372231

Surat Keterangan Sakit

Yang beratanda tangan di bawah ini :

Dr. ............................................................................................................................. .........

Menerangkan bahwa ....................................................................................................... ..

Karena sakit harus istirahat di rumah ................................................................................

Dari tanggal ........................................s/d........................(............................hari lamanya)

Tangerang ................................20.......

Dokter yang memeriksa

(..................................................)
 Klinik
BSD

JL Raya Serpong Sektor VII, Bolk RP No 92 BSD

Telp./Fax. 021 5372231

SURAT RUJUKAN
Kepada Yth.

T.S. Dr. .......................................

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

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

Dengan hormat,

Mohon bantuannya untuk pemariksaan / pengobatan / pearawatan penderita :

Nama :...............................................................................................

Umur : ..............................................................................................

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

Keluhan utama : ..............................................................................................

Pemeriksaan fisik : ...............................................................................................

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

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

Laboratorium : ..............................................................................................

Lain-lain : ..............................................................................................

Diagnosa sementara : ..............................................................................................

Terima kasih banyal atas bantuan dan kerjasamanya.

Tangerang,...................................................

Dokter yang memeriksa,

 Klinik
BSD

JL Raya Serpong Sektor VII, Bolk RP No 92 BSD

Telp./Fax. 021 5372231

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