“FAOLINGGA”
Bidan Ny. Amila Ns.
Ds. Margomulyo, Kec. Watulimo, Kab. Trenggalek
No. HP 081363205519
Kepada Yth. :
Rumah Sakit / RSIA
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Di…………………….
SURAT RUJUKAN
Nomor : / / BPM / 20
Nama : …………………………………………………………………………….
Umur : …………………………………………………………………………….
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Margomulyo, ……………..2020