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RUJUKAN Probolinggo, ....................... 20.....

KEPADA YTH :
Ts. Dr. ............................................
Di.........................................
Ts. Yth :
Dengan ini kami kirimkan penderita
Nama : ...................................................
Umur : ...................................................
Jenis kelamin : ..................................................
Alamat : .................................................
Yang menurut kami menderita ..................................................................................................................

Pengobatan yang sudah kami berikan .......................................................................................................

Mohon perawatan lebih lanjut / konsultasi.


Sebelumnya kami ucapkan terimakasih. Salam sejawat

(Dr. ......................................)

JAWABAN RUJUKAN Probolinggo, ............................20..................


KEPADA YTH. :
Ts. Dr. ............................................................
Di Rumah Sakit DHARMA HUSADA
PROBOLINGGO

Ts. Yth :
Pasien kiriman saudara
Nama :.................................................................
Umur :.................................................................
Jenis Kelamin :.................................................................
Alamat :.................................................................
Menurut diagnosa kami, menderita ...........................................................................................................

Pasien yang bersangkutan perlu : Opname / Perawatan Lanjutan / Kami kembalikan kepada Ts.
Pengobatan : ..........................................................................................................................

Advis / Saran : ..........................................................................................................................

Usul : ..........................................................................................................................

Terima kasih Salam Sejawat,

(Dr. ...............................................)
JAWABAN RUJUKAN Probolinggo, ............................20..................
KEPADA YTH. :
Ts. Dr. ............................................................
Di Rumah Sakit DHARMA HUSADA
PROBOLINGGO

Ts. Yth :
Pasien kiriman saudara
Nama :.................................................................
Umur :.................................................................
Jenis Kelamin :.................................................................
Alamat :.................................................................
Menurut diagnosa kami, menderita ...........................................................................................................

Pasien yang bersangkutan perlu : Opname / Perawatan Lanjutan / Kami kembalikan kepada Ts.
Pengobatan : ..........................................................................................................................

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