SURAT KETERANGAN

Kepada Yth ..........................

Dengan ini menyatakan bahwa pasien atas :
Nama : ............................................
Umur : ............................................
Diagnosa : ............................................
Alasan Pindah RS : ............................................
Keluhan Utama :
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Tindakan Yang Sudah Dilakukan :
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Catatan : Pasien dibawa sendiri oleh keluarga dengan segala resiko dengan
Alasan : .........................................................................................................

Bekasi, ................................
Keluarga Yang Bersangkutan Dokter

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