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PRAKTEK DOKTER UMUM

dr. Galih Mega Putra


Dsn. Jeruk Desa Tugurejo Kec. Ngasem Kabupaten Kediri – Jawa Timur

Kepada
Yth. :.............................................
Di RS :.............................................

Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita,

Nama Pasien :...................................................


Jenis Kelamin :....................................................
Umur :....................................................
No. Telpon :....................................................
Alamat Rumah :....................................................

Hasil anamnesis :

Keluhan :
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Diagnosis sementara : ...................................................................................................

Terapi/Obat yang telah diberikan : ..........................................................................................


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Demikian surat rujukan ini kami kirim, kami mohon balasan atas surat rujukan ini. Atas
perhatiannya saya ucapkan terima kasih.

Hormat Kami

(..............................)

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