PEMERINTAH KABUPATEN BUTON SELATAN

RUMAH SAKIT UMUM DAERAH

Jln. Gajah Mada No........ Telp......./Fax (0204)
BATAUGA

SURAT RUJUK BALIK

Yth : dr............................................
Di : ..............................................

Mohon pemeriksaan

No. Rekam Medis :

Nama :
Diagnosa :
Terapi :

Tindak lanjut yang di anjurkan

 Pengobatan dengan obat-obatan :
.......................................................... X ...................................................................

........................................................... X ..................................................................

............................................................ X ..................................................................

 Lain-lain :
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Batauga, ..................................................
Dokter Pemeriksa

(dr. ..........................................)