PEMERINTAH KABUPATEN PATI PEMERINTAH KABUPATEN PATI

DINAS KESEHATAN KABUPATEN PATI DINAS KESEHATAN KABUPATEN PATI

PUSKESMAS GEMBONG PUSKESMAS GEMBONG
Jl. Raya Kecamatan Gembong KM.14 Kode Pos 59162 Jl. Raya Kecamatan Gembong KM.14 Kode Pos 59162
Telp. (0295) 4101507 email : puskesmasgembong@gmail.com Telp. (0295) 4101507 email : puskesmasgembong@gmail.com

FORMULIR RUJUKAN INTERNAL FORMULIR RUJUKAN INTERNAL

Nama Pelayanan Pengirim : ...................................................................... Nama Pelayanan Pengirim : ......................................................................

Nama Pelayanan yang dituju : ...................................................................... Nama Pelayanan yang dituju : ......................................................................
Nama Pasien : ...................................................................... Nama Pasien : ......................................................................
Umur : ...........Tahun, Jenis Kelamin : L / P Umur : ...........Tahun, Jenis Kelamin : L / P
No. Rekam Medik : ...................................................................... No. Rekam Medik : ......................................................................
No. Identitas : NIK................................................................. No. Identitas : NIK.................................................................
KS.................................................................. KS..................................................................
Alamat Lengkap : ...................................................................... Alamat Lengkap : ......................................................................
...................................................................... ......................................................................
Jenis Pemeriksaan : ...................................................................... Jenis Pemeriksaan : ......................................................................

Gembong, ……………………………. Gembong, …………………………….

Pelayanan Pengirim Pelayanan Pengirim

( ) ( )
NIP. NIP.

FORMULIR UMPAN BALIK FORMULIR UMPAN BALIK

Nama Penderita : ...................................................................... Nama Penderita : ......................................................................

Umur : ...........Tahun, Jenis Kelamin : L / P Umur : ...........Tahun, Jenis Kelamin : L / P
Pelayanan yang mengirim : ...................................................................... Pelayanan yang mengirim : ......................................................................
Hasil Pemeriksaan : ...................................................................... Hasil Pemeriksaan : ......................................................................

Gembong, ……………………………. Gembong, …………………………….

Pelayanan Pengirim Pelayanan Pengirim

( ) ( )