SURAT RUJUKAN SURAT RUJUKAN

Nomor: ............................................... Nomor: ...............................................

Kepada Yth: Kepada Yth:

............................................................. .............................................................
............................................................. .............................................................
Bersama ini Kami Kirimkan Bersama ini Kami Kirimkan
Nama : ................................................................................................... Nama : ...................................................................................................
Umur : ................................................................................................... Umur : ...................................................................................................
Alamat : ................................................................................................... Alamat : ...................................................................................................
................................................................................................... ...................................................................................................
Diagnosa : ................................................................................................... Diagnosa : ...................................................................................................
Mohon untuk pemeriksaan: Mohon untuk pemeriksaan:
 Golongan darah  PITC  Golongan darah  PITC
 HB  BTA  HB  BTA
 Protein urin  Shipilis  Protein urin  Shipilis
 Reduksi urin  HIV  Reduksi urin  HIV
 IMS  HBSAG  IMS  HBSAG

Terimakasih atas kerjasamanya Terimakasih atas kerjasamanya

Bandung, ......................................... Bandung, .........................................
Salam Sejawat Salam Sejawat