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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.