SURAT RUJUKAN BALIK

PEMERIKSAAN KESEHATAN
Nomor :

Kepada Yth.
Sejawat Dokter Pemeriksa Kesehatan Dasar
Puskesmas ...........................................

Dengan ini kami kirimkan kembali jemaah haji :

Nama : ..................................................................................................................

Bin/binti.....................................................................................................
Umur : ...................... tahun
Jenis Kelamin : ..................................................................................................................
Alamat tinggal : ..................................................................................................................
..................................................................................................................
Kab/Kota...................................................................................................
Diagnosis : ..................................................................................................................
..................................................................................................................
..................................................................................................................
Untuk dilakukan pemeliharaan kesehatan lebih lanjut.

Terapi yang sudah diberikan :............................................................................................

............................................................................................................................................
............................................................................................................................................
............................................................................................................................................

Saran terapi selanjutnya ....................................................................................................

............................................................................................................................................
............................................................................................................................................
............................................................................................................................................

....................., …................20….
Pemeriksa Kesehatan Lanjutan
RS ...................................................

dr. .................................................
NIP,SIP...........................................

Keterangan :
 *) Kode Diagnosis ditulis menurut klasifikasi ICD-X
 Dibuat rangkap 3 untuk keperluan :
1. Puskesmas
2. Dinas Kesehatan Kabupaten/Kota
3. Arsip