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BLANKO RUJUKAN .............................,................................, 200 ............

Kepada Yth. :

Dokter jaga / dr. ...................................................


Di : .......................................................................

Dengan hormat, bersama dengan ini kami kirimkan penderita dengan data sebgai berikut:

Nama : .................................................... Umur : ............. th./bl./hr.


Alamat : .................................................................................................
Keluhan Utama : .................................................................................................
..................................................................................................
Diagnosa Kerja : .................................................................................................
Terapi yang sudah : ................................................................................................
Diberikan : ................................................................................................
.................................................................................................
Mohon pemeriksaan / perawatan lebih lanjut atas penderita tersebut, terima kasih.

Hormat Kami
DATA PERUJUK
Nama Lengkap : ..................................................
Alamat : ..................................................
Telp. : .................................................. .......................................................

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