PEMERINTAH KABUPATEN MURUNG RAYA

DINAS KESEHATAN
UPT PUSKESMAS PURUK CAHU SEBERANG
Jl. Bhayangkara No.53B (0528……) Kec. Murung Kode Pos ( 73911)
email : pkm.purukcahuseberang12@gmail.com

FORMULIR RUJUKAN INTERNAL

Nama Poli Pengirim :.........................................................................................

Nama Poli yang di tuju :..........................................................................................
Nama Pasien :......................................umur.............Jenis kelamin : L /P
No. Rekam Medik :..........................................................................................
Alamat Lengkap :..........................................................................................
...........................................................................................
Jenis Pemeriksaan :..........................................................................................

Puruk Cahu Seberang,........................

Poli Pengirim

NIP.

FORMULIR UMPAN BALIK

Nama Penderita :........................................................................................
Umur :..................Tahun Jenis Kelamin : L/P
Nama Poli yang mengirim :........................................................................................
Hasil Pemeriksaan :........................................................................................

Puruk Cahu Seberang,............................

Poli Penerima

NIP.