PEMERINTAH KABUPATEN ROTE NDAO

PUSKESMAS DELHA
Jln. Baa-Nemberala km 37
No.Telp 081282313050 Email :pkmdelh@gmail.com

BUKTI UMPAN BALIK RUJUKAN

Wonosobo, 2013
Keterangan ( diisi oleh konsulen atau dokter yang menerima rujukan )
Nama penderita :...........................................................................
Umur :...........................................................................
Alamat :...........................................................................
Pekerjaan :...........................................................................
Diagnosis :...........................................................................
Therapi :...........................................................................
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Dokter yang menerima rujukan

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1. Perlu kontrol kembali :..........................................

2. Perlu konsultasi ahli lain :..........................................
3. Konsultasi selesai :..........................................

Lembar ini dikembalikan kepada pengirim setiap kali selesai konsul tasi