PEMERINTAH KABUPATEN SOLOK

DINAS KESEHATAN
PUSKESMAS SURIAN KECAMATAN PANTAI CERMIN

SURAT RUJUKAN PESERTA UMUM / JKN

No. ....................................................................................

Kepada Rumah Sakit ................................................................................................ Di .....................................................................................

Bagian .........................................................................................................................................................................................................................

TS, Yth
Mohon Pemeriksaan Dan Pengobatan Lebih Lanjut Terhadap Penderita :
Nama : Umur : P/S/I/A ke
Nomor Kartu JKN :
Diagnosa Sementara / Keluhan :
........................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................

Atas Pertolongan TS Kami Ucapkan Terima Kasih, Mohon Informasi Selanjutnya

................................. , ....................................... 20 ........

Dokter Puskesmas

( ......................................................................... )
NIP. ....................................................................

SURAT RUJUKAN BALIK

No. ....................................................................................

TS, Yth
Dikirim Kembali Penderita Untuk Ditindak Lebih Lanjut :
Nama : Umur : P/S/I/A ke
Nomor Kartu JKN :
Diagnosa Sementara / Keluhan :
........................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................
........................................................................................................................................................................................................................................

Tindak Lanjut Dianjurkan :

1. Pengobatan ..............................................................................................................................................................................................
2. Kontrol Kembali Ke Rumah Sakit ...................................................................................................................................................
3. Pelayanan / Tindakan Medis Yang Dihasilkan .........................................................................................................................
a. Penunjang Diagnosa .....................................................................................................................................................................
b. Tindakan ...........................................................................................................................................................................................
c. Perawatan .........................................................................................................................................................................................

................................. , ....................................... 20 ........

Dokter Pengiriman