PEMERINTAH KABUPATEN LUWU UTARA Penderita Yang di rujuk dengan..........................................................................................

DINAS KESEHATAN Surat Rujukan.......................................................................................................................

UPT PUSKESMAS RAMPI Nomor..................................................................................................................................

Alamat : Dusun Lapangan Desa Sulaku Kecamatan Rampi TS Yth,

Email : Puskesmasrampi@gmail.com, Rampi kode pos 92964
Kami Kirim Kembali
SURAT RUJUKAN PENDERITA Nama :
Umur :
No. Rujukan:......................................................................................................................
Alamat :
Kepada Yth. TS Dr. UGD/Poliklinik:....................................................................................
Di RS :.................................................................................................................................
Diagnosa :
Mohon Pemeriksaan dan Penanganan Lebih lanjut penderita : 1. Telah di berikan Pengpbatan...................................................................................
Nama/Umur/JK : ………………………………………………………/………..tahun,(P/L) .................................................................................................................................
Alamat : …………………………………………………………………………………. .................................................................................................................................
Jenis Kepesertaan :………………………………………………………………………………….. .................................................................................................................................
No. BPJS/KIS :………………………………………………………………………………….. 2. Keterangan Pengobatan Ya:
Keluhan/Anamnesa :………………………………………………………………………………………………. Penunjang Diagnosa:...............................................................................................
.................................................................................................................................
Pemeriksaan Fisik:............................................................................................................. .................................................................................................................................
........................................................................................................................................... .................................................................................................................................
........................................................................................................................................... Tindakan Pengobatan..............................................................................................
Diagnosa Sementara:......................................................................................................... .................................................................................................................................
........................................................................................................................................... .................................................................................................................................
Resume Medis................................................................................................................... .................................................................................................................................
........................................................................................................................................... 3. Disarankan untuk control kembali tanggal:.............................................................
...........................................................................................................................................
Demikian Atas Bantuannya, di Ucapkan Terima kasih. Dokter Pemeriksa,
Rampi,……………………………. Bagian Ahli,
Dokter Pemeriksa,
SURAT RUJUKAN BALIK
( )
( dr. Nelvi Utami Putri Kawile )
Nip19920525 202012 2 007