DINAS KESEHATAN KABUPATEN SUKABUMI

DINAS KESEHATAN
PUSKESMAS CIBOLANG
Jalan Veteran Km. 4 Desa Cibolang Kecamatan Gunnungguruh
Email : cibolangpuskesmas@gmail.com Cibolang - 43156

FORMULIR RUJUKAN INTERNAL

NO RM : ....................................................................................................

JENIS PASIEN : (UMUM/BPJS) *coret yang tidak perlu

ASAL RUANG : ....................................................................................................

TUJUAN RUANG : ....................................................................................................

NAMA PASIEN : ....................................................................................................

UMUR : ................. tahun. Jenis Kelamin: L/P

ALAMAT : ....................................................................................................

KELUHAN : ....................................................................................................

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

DIAGNOSIS SEMENTARA : ....................................................................................................

CATATAN : ....................................................................................................

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

Cibolang, ...................................

Pemeriksa

(..................................................)
 FORMULIR RUJUKAN BALIK INTERNAL

NAMA PASIEN : ............................................................................

UMUR : ..................... tahun. Jenis Kelamin: L/P

NAMA RUANGAN YANG MENGIRIM : ............................................................................

KELUHAN : ............................................................................

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

HASIL PEMERIKSAAN : ............................................................................

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

DIAGNOSIS : ............................................................................

TINDAK LANJUT : ............................................................................

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

Cibolang,....................................

Pemeriksa

(..............................................)