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PRAKTIK MANDIRI BIDAN

DESI PERMATASARI D
DESA ALASMALANG

SURAT RUJUKAN

Kemranjen, ...................................
Kepada Yth ....................................
.................................
Di .......................................

Mohon pemeriksaan /pengobatan lebih lanjut terhadap penderita :


Nama Ibu : ..............................................................
Umur : ..............................................................
Nama Suami : ..............................................................
Pekerjaan : ..............................................................
Alamat : ..............................................................
Anamnesa : ..............................................................
: ...............................................................
Pemeriksaan Fisisk : ..............................................................
...............................................................
................................................................
Obat yang diberikan : ..............................................................
...............................................................
Diagnosa Sementara : ...............................................................

Atas kerjasamanya kami haturkan terima kasih.

Kemranjen, .................................20
Bidan Yang merujuk

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