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DINAS KESEHATAN KABUPATEN KONAWE SELATAN
PUSKESMAS BASALA
JalanPorosBasala – Benua, Kec. Basala
No.Telp 085338867895 Email : puskesmasbasala@yahoo.com
SURAT RUJUKAN PASIEN UMUM

No :445/ /Pusk-Bsl./ /2020
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Bagian : .............................
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Bersamaini kami rujukpasien :
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Umur : ……………………………………………...
Resume Medis
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Mohon Konsul Untuk
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Ataskerjasamanya kami ucapkanterimakasih.

Basala, …………………………. 2020
Dokter / Bidan
PKM Basala
( ……………………………………. )

PUSKESMAS BASALA
SURAT RUJUKAN PASIEN BPJS

No :445/ /Pusk-Bsl./ /2020
KepadaYth. TS :...............................
Bagian : .............................
Di :............................................
Nama : ……………………………………………… L/P
Alamat : ………………………………………………
Umur : ……………………………………………....
No. Kartu : ………………………………………………
No. Rujuk Lanjut : ........................................................................
Resume Medis
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O...............................................................................................................................
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A...............................................................................................................................
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Mohon Konsul Untuk
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Ataskerjasamanya kami ucapkanterimakasih.
Basala, …………………………. 2020
Dokter / Bidan
PKM Basala
( ……………………………………. )

PUSKESMAS BASALA
SURAT RUJUKAN PASIEN JAMPERSAL

No :445/ /Pusk-Bsl./ /201
KepadaYth. TS :...............................
Bagian : .............................
Di :............................................
Nama : ……………………………………………… L/P
Alamat : ………………………………………………
Umur : ……………………………………………....
No. Kartu : ………………………………………………
No. Rujuk Lanjut : ........................................................................
Resume Medis
S................................................................................................................................
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O...............................................................................................................................
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A...............................................................................................................................
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Mohon Konsul Untuk
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AtasKerjasamanya kami ucapkanterimakasih

Basala, …………………………. 201
Dokter / Bidan
PKM Basala
( ……………………………………. )

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DINAS KESEHATAN KABUPATEN KONAWE SELATAN

SURAT RUJUKAN PASIEN UMUM

Ataskerjasamanya kami ucapkanterimakasih.

DINAS KESEHATAN KABUPATEN KONAWE SELATAN

SURAT RUJUKAN PASIEN BPJS

Bersamaini kami rujukpasien :

Nama : ……………………………………………… L/P

No. Kartu : ………………………………………………

No. Rujuk Lanjut : ........................................................................

DINAS KESEHATAN KABUPATEN KONAWE SELATAN

SURAT RUJUKAN PASIEN JAMPERSAL

Bersamaini kami rujukpasien :

Nama : ……………………………………………… L/P

No. Kartu : ………………………………………………

No. Rujuk Lanjut : ........................................................................

AtasKerjasamanya kami ucapkanterimakasih

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