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