Kepada Yth,
..............................................................
Di Tempat
Berdasarkan hasil pemeriksaan pada pasien :
Nama : .........................................................................................................................
No. MR : .........................................................................................................................
Diagnosa : .........................................................................................................................
Maka perlu diberikan tindakan berupa kegiatan rehabilitasi psikososial di Inst. Rehabilitasi Medik
Psikiatri :
................................................................................................................................................................
Medan, ............................................
Kepala Instalasi Rehabilitasi Mental dan Sosial
( ....................................... )