RS AIRLANGGA

Jl. Airlangga 50 C JelakOmbo Jombang Telp. 0321-861577

SURAT KONTROL RAWAT INAP

No:……………….

Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Tanggal Keluar : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................

Jombang, .................................................
Petugas

( )

SURAT PENGANTAR RAWAT INAP

(No:…….…..…..)
Yang bertanda tangan dibawah ini, memberikan pengantar rawat inap kepada pasien :

Nama : ……………………………………………………………………………………………. Laki-laki / Perempuan*

No. RM : ………………………………………….. Jaminan :  Umum  BPJS  PT  Asuransi
No. BPJS : …………………………………………………………………………………………………………………………………….
Tgl. Lahir / Umur : ……………………………./…………… Thn / Bln / Hr
Alamat : …………………………………………………………………………………………………………………………………….
Diagnosa : …………………………………………………………………………………………………………………………………….
Dr / Dr. Spesialis : …………………………………………………………………………………………………………………………………….
Untuk dirawat di ruang : …………………………………………………………………………… Kelas :……………………….………..
Jombang,
Dokter yang memeriksa

(…………………………………………………)
*) Lingkari yang sesuai
 RS AIRLANGGA
Jl. Airlangga 50 C JelakOmbo Jombang Telp. 0321-861577

SURAT KONTROL RAWAT JALAN

No:……………….

Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................

Jombang, .................................................
Petugas

( )

RS AIRLANGGA
Jl. Airlangga 50 C JelakOmbo Jombang Telp. 0321-861577

SURAT KONTROL RAWAT JALAN

No:……………….

Nomor RM : ......................................................................................................
Nama : ......................................................................................................
Tanggal Lahir / Umur : .............................................../......................................Bln / Thn
Alamat : ......................................................................................................
Tanggal Masuk : ......................................................................................................
Diagnosa : ......................................................................................................
Therapy Pulang : ......................................................................................................
Tanggal Kontrol : ......................................................................................................

Jombang, .................................................
Petugas

( )