Anda di halaman 1dari 2

AMORE ANIMAL CLINIC 4

Jl Kemang Utara no. 24


Bangka, Mampang Prapatan, Jakarta Selatan 12730
Telp. 0822 6161 3379
Email : clinicamore@gmail.com

SURAT RUJUKAN

Yth. Kolega drh. …………………….


di tempat

Dengan hormat,
Bersama ini kami kirimkan pasien dengan data-data sebagai berikut :
Nama hewan : .........................................................................................................
Jenis kelamin / Usia : .........................................................................................................
Ras / warna hewan : .........................................................................................................
Nama pemilik : .........................................................................................................
Alamat pemilik : .........................................................................................................
No. telp : .........................................................................................................
Anamnesa : ..........................................................................................................................................
...................................................................................................................................................................
Hasil pemeriksaan / kondisi selama dirawat :
................................................................................. ……………………………………………………………
....................................................................................................................................................................
....................................................................................................................................................................
....................................................................................................................................................................
Diagnosa : .............................................................................................................................................
Pengobatan yang sudah diberikan :
....................................................................................................................................................................
....................................................................................................................................................................
Saran : ..............................................................................................................................................

Kami mohon bantuan untuk second opinion dan perawatan lebih lanjut. Atas
perhatian dan kerjasamanya, kami ucapkan banyak terima kasih.

Jakarta, …………………….….………….
Hormat Kami,

(……………………………………………)
AMORE ANIMAL CLINIC 4
Jl Kemang Utara no. 24
Bangka, Mampang Prapatan, Jakarta Selatan 12730
Telp. 0822 6161 3379
Email : clinicamore@gmail.com

Anda mungkin juga menyukai