DINAS KESEHATAN KABUPATEN BONDOWOSO

PUSAT KESEHATAN MASYARAKAT TAMANAN

Jl. Maesan No. 50 Telp (0332) 426203 Tamanan

FORM RUJUKAN INTERNAL

Unit Pengirim : ____________________________________________________________________

Unit Tujuan : ____________________________________________________________________

Nama Pasien : _____________________________ Umur : _________ Jenis Kelamin :L/P

No. Rekam Medis : ____________________________________________________________________
Alamat : ____________________________________________________________________
Hasil Pemeriksaan : ____________________________________________________________________
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Diagnosis : ____________________________________________________________________
Terapi : ____________________________________________________________________
Advice : ____________________________________________________________________

Tamanan, ______________

Unit Pengirim

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FORM UMPAN BALIK

Unit Pengirim : ____________________________________________________________________

Unit Tujuan : ____________________________________________________________________

Nama Pasien : _____________________________ Umur : _________ Jenis Kelamin :L/P

No. Rekam Medis : ____________________________________________________________________
Alamat Lengkap : ____________________________________________________________________
Hasil Pemeriksaan : ____________________________________________________________________
____________________________________________________________________
Rekomendasi : ____________________________________________________________________
Terapi : ____________________________________________________________________

Tamanan, ______________

Unit Penerima

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