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IKATAN BIDAN INDONESIA IKATAN BIDAN INDONESIA

PMB / RB : .......................................... PMB / RB : ..........................................

RUJUKAN IBU RUJUKAN BAYI


No. : .................................. No. : ..................................
....................., ........................... ....................., ...........................

Kepada Yth. Kepada Yth.


........................................... ...........................................
........................................... ...........................................
di ....................................... di .......................................

Dengan Hormat, Dengan Hormat,


Bersama ini kami mengirimkan penderita Bersama ini kami mengirimkan penderita
Nama : Ny. .......................................... Umur ............ tahun Nama : .............................................. Umur .............. tahun
Pendidikan .................................................................................
: Alamat : .................................................................................
Alamat : ................................................................................. Keterangan : G ................... P ....................... BB ...................Kg.
Keterangan : G ................... P ....................... BB ...................Kg. TB ................. cm / Tensi ............... HB ...................
TB ................. cm / Tensi ............... HB ...................
Pada Pemeriksaan kami :
Pada Pemeriksaan kami : ................................................................................................................
................................................................................................................ ................................................................................................................
................................................................................................................ ................................................................................................................
................................................................................................................ ................................................................................................................
................................................................................................................ ................................................................................................................
................................................................................................................ Mohon pemeriksaan / pertolongan perawatan selanjutnya
Mohon pemeriksaan / pertolongan perawatan selanjutnya Sekian terima kasih
Sekian terima kasih
Hormat kami Hormat kami
Bidan, Bidan,

(...........................) (...........................)

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