PEMERINTAH KABUPATEN MUARO JAMBI PEMERINTAH KABUPATEN MUARO JAMBI

DINAS KESEHATAN DINAS KESEHATAN

PUSKESMAS PENYENGAT OLAK PUSKESMAS PENYENGAT OLAK
JL. Lintas Timur Sumatera Desa Penyengat Olak JL. Lintas Timur Sumatera Desa Penyengat Olak
PENYENGAT OLAK PENYENGAT OLAK

FORMULIR RUJUKAN KEGIATAN LUAR GEDUNG FORMULIR RUJUKAN KEGIATAN LUAR GEDUNG

Nama Kegiatan : Posbindu/………………../Posyandu Lansia/ ............. Nama Kegiatan : Posbindu/………………../Posyandu Lansia/ .............
Nama Puskesmas : ............................................................................... Nama Puskesmas : ...............................................................................
Nama Poli yang dituju : ............................................................................... Nama Poli yang dituju : ...............................................................................
Nama Pasien :…………………………Umur:…………..Jenis Kelamin: P / L Nama Pasien :…………………………Umur:…………..Jenis Kelamin: P / L
Alamat Lengkap :................................................................................ Alamat Lengkap : ...............................................................................
Hasil Labor Hasil Labor
- Gula : ............................................................................... - Gula : ...............................................................................
- Kolesterol : ............................................................................... - Kolesterol :................................................................................
- Asam Urat : ................................................................................ - Asam Urat : ................................................................................
Tindak Lanjut : ................................................................................ Tindak Lanjut : ................................................................................
Penyengat Olak,…………………..20… Penyengat Olak,…………………..20…
Poli Pengirim Poli Pengirim

NIP. NIP.
.................................................................................................................................... ....................................................................................................................................
FORMULIR UMPAN BALIK FORMULIR UMPAN BALIK
Nama Penderita :………………………… Umur:…………..Jenis Kelamin: P / L Nama Penderita :………………………… Umur:…………..Jenis Kelamin: P / L
Nama Poli Pengirim : ....................................................................................... Nama Poli Pengirim : .......................................................................................
Hasil Pemeriksaan : ....................................................................................... Hasil Pemeriksaan : ......................................................................................
Penyengat Olak,…………………..20… Penyengat Olak,…………………..20…
Poli Penerima Poli Penerima

NIP. NIP.