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PEMERINTAH KABUPATEN SOLOK

DINAS KESEHATAN
PUSKESMAS SULIT AIR
KECAMATAN X KOTO DIATAS

Jl Balik Parit Sulit Air puskesmassulitair1@gmail.com

SURAT RUJUKAN
No. /2019

Kepala Rumah Sakit,.......................................................................................................... ....................


Bagian........................................................................................................ ..............................................
TS Yth,
Mohon pemerIksaan dan pengobatan lebih lanjut terhadap penderita :
Nama : ................................................................................ .....................
Umur : ................................................................................ .....................
Kelamin : ....................................................................................................
No bpjs : ................................................................................ ....................
Dengan Diagnosa / keluhan : ............................................................................................... .....
Terima kasih, mohon informasi selanjutnya

Sulit Air .............................2019


Therapi yang telah dilakukan
......................................................................
......................................................................
..................................................................... dr.DWI PUTRI LOVITA
......................................................................

SURAT RUJUKAN BALIK

TS Yth, ......................................
Dikirim kembali penderita untuk tindak lanjut :
Nama : ----------------------------------------
Umur : ----------------------------------------
Kelamin : ----------------------------------------
Diagnosa : ----------------------------------------
Tindak lanjut yang dianjurkan :
1.Pengobatan : -----------------------------------------
-----------------------------------------
-----------------------------------------
1. Kontrol kembali : -----------------------------------------

.......................Tgl................................
Dokter Pengirim

-----------------------------------

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