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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,