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dr....................................................

SIP. ........................
Praktek:
RS Unila Jl. Ir. Soemantri Brojonegoro
No. Telp 08123456789

SURAT RUJUKAN

Yth Dokter : ...............................................................


Di RS :.................................................................

Mohon pemeriksaan dan penanganan lebih lanjut terhadap penderita,


Nama pasien : ..........................................................................
Jenis Kelamin : ..........................................................................
Umur :...........................................................................
No. Telpon :...........................................................................
Alamat :...........................................................................

Anamnese
Keluhan :...........................................................................
Diagnosis sementara :...........................................................................
Kasus :...........................................................................
Terapi obat yang diberikan :...........................................................................

Demikian surat rujukan ini kami kirim, kami mohon balasan atas surat rujukan ini. Atas
perhatian Bapak/ Ibu kami ucapkan terimakasih.

Hormat Kami,

(dr...........................................)

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