BPM / RB :......................................................................
RUJUKAN
..........................Tgl....................
Kepada Yth. :
...................................................
..................................................
Dengan hormat,
Mohon pertolongan selanjutnya pada :
Nama : ..........................................................................................................................................
Umur : ..........................................................................................................................................
Alamat : ..........................................................................................................................................
Anamnese :
Tindakan / pemeriksaan :
Perkiraan Diagnosa :
Demikian, atas bantuanya diucapkan terima kasih.
BIDAN
( )