SURAT RUJUKAN SURAT RUJUKAN

NO :....................................... NO :.......................................

Saya yang bertanda tangan di bawah ini, dengan ini merujuk pasien a/n : Saya yang bertanda tangan di bawah ini, dengan ini merujuk pasien a/n :

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

Umur : .................................................................. Umur : ..................................................................

Jenis Kelamin :.................................................................... Jenis Kelamin :....................................................................

Pekerjaan : .................................................................... Pekerjaan : ....................................................................

Alamat : .................................................................... Alamat : ....................................................................

Diagnosa : .................................................................... Diagnosa : ....................................................................

Pengobatan yang sudah diberikan : Pengobatan yang sudah diberikan :

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

Demikian atas kerjasamanya kami ucapkan terima kasih. Demikian atas kerjasamanya kami ucapkan terima kasih.

Ciranjang, ..............................20....... Ciranjang, ..............................20.......

Pemeriksa Pemeriksa

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