PEMERINTAH KABUPATEN PANDEGLANG

JAWABAN RUJUKAN
DINAS KESEHATAN KABUPATEN PANDEGLANG
UPT PUSKESMAS CIGEULIS Cigeulis, ......................... 20 .....
Alamat : Jl. Raya Cibaliung Km. 16. Cigeulis Pandeglang 42282
Nama : ..........................................................................
SURAT RUJUKAN UMUM/JKN Hub. Keluarga : P/I/S/A Umur : ............... Kelamin L / P
No. ............/Reg/PKM/.................../........../......... Nama Pasien : ..........................................................................
Nomor CM : ..........................................................................
Cigeulis, ...........................20 .... Alamat Rumah : ..........................................................................
Yth, TS. Dokter Ahli : Telp. : ..........................................................................

RS : .................................... Keterangan (diisi oleh konsultan)

Mohon pemeriksaan/pengobatan lebih lanjut terhadap penderita,
Nama Pasien : .......................................................................... Konsul selesai
Hub. Keluarga : P/I/S/A Umur : ............... Kelamin L / P Perlu kontrol kembali (sebutkan) ...............................................................................
Nama Pasien : .......................................................................... Perlu konsul ke ahli lain (sebutkan) ...........................................................................
Nomor CM : .......................................................................... Perlu tindakan medis lain (sebutkan) .........................................................................
Alamat Rumah : .......................................................................... Perlu dirawat dengan indikasi (sebutkan) ..................................................................
Telp. : ..........................................................................
Hasil Pemeriksaan Penunjang :
Anamnesa : ................................................................................................................................................
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................................................................................................................................. Diagnosa : ..............................................................................................................................
Terapi yang sudah
Pemeriksaan Fisik : dilakukan :..............................................................................................................................................
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Anjuran :
Diagnosa Sementara : ................................................................................................................................................
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................................................................................................................................................ Salam Sejawat

Terapi/Obat yang telah diberikan :

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Salam Sejawat Tanggal dan Catatan konsul/kontrol selanjutnya :
Tgl. Catatan konsul/kontrol selanjutnya : Paraf Dokter

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