Logo PEMERINTAH KOTA MEDAN

Logo
Dinkes
Kota
DINAS KESEHATAN Puskesmas
Medan
UPT PUSKESMAS PADANG BULAN
Jl. .............................

FORMAT RUJUKAN INTERNAL

Nama : ..................................................................................................
No RM : ..................................................................................................
Usia : ..................................................................................................
Asal Ruangan/Unit : ..................................................................................................
Keluhan Pasien : ..................................................................................................
..................................................................................................
Gejala TBC : ada / tidak
Rujukan ke : ..................................................................................................

o Pelayanan Umum o Klinik Terpadu

o Pelayanan TBC o Pelayanan Kesling
o Pelayanan Persalinan o Promkes
o Pelayanan Gawat Darurat o UKS
o Pelayanan Laboratorium o Posyandu Balita
o Pelayanan KIA/KB o Posyandu Lansia
o Pelayanan MTBS o PTM
o Pelayanan Gigi

Ket:

Kota Medan, .................................................

Petugas Yang Meminta,

_______________________________