PEMERINTAH KOTA BONTANG

DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT BONTANG SELATAN I
Jl. Cumi - Cumi No. 08 RT 01 TanjungLaut Indah Telp (0548) 3552703 KodePos 75322
BONTANG - KALIMANTAN TIMUR

SURAT RUJUKAN

Kepada : ........................................
Di ....................................

Mohon pemeriksaan dan penangan lebih lanjut terhadap pasien sebagai berikut,

Nama pasien : .......................................................................................................................

Jenis kelamin : L/P
Umur : ......................................................................................................................
No. telepon : ......................................................................................................................
Alamat rumah : ......................................................................................................................
Anamnese : ......................................................................................................................
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Pemeriksaan fisik : ......................................................................................................................
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Pemeriksaan penunjang : ......................................................................................................................
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Diagnosa Sementara : ........................................................................................................................
Terapi dan obat yang : .......................................................................................................................
.........................................................................................................................
telah diberikan
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Mohon pemeriksaan dan penatalaksanaan lebih lanjut, atas perhatiannya diucapkan terima kasih.

Hormat Kami

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