PEMERINTAH KABUPATEN PENAJAM PASER UTARA

DINAS KESEHATAN
UPT. PUSKESMAS PETUNG
JL.NEGARA KM. 18 KEC.PENAJAM KODE POS 76144 TELP.0543-5232949

RUJUKAN INTERNAL

Unit Pengirim :.........................................................................................................................

Unit Tujuan :.........................................................................................................................
Nama Pasien :......................................................Umur:.................Jenis Kelamin : L/P
Alamat Lengkap :.........................................................................................................................
Hasil Pemeriksaan :.........................................................................................................................
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Diagnosa :.........................................................................................................................
Tindakan :.........................................................................................................................

Petung,................................................
Pengirim,

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RUJUKAN BALIK

Unit Pengirim :.........................................................................................................................

Unit Tujuan :.........................................................................................................................
Nama Pasien :......................................................Umur:.................Jenis Kelamin : L/P
Alamat Lengkap :.........................................................................................................................
Hasil Pemeriksaan :.........................................................................................................................
..........................................................................................................................
Diagnosa :.........................................................................................................................
Rekomendasi :........................................................................................................................

Petung,................................................
Pengirim,

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