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KLINIK PRATAMA

DAN RUMAH BERSALIN


ANANDA MEDIKA
Jl. Depati Purbo RT 16 Simp. Perumahan Lazio
Kelurahan Pematang Sulur Kecamatan Telanai Pura Kota Jambi
NO. HP 081260651401

SURAT RUJUKAN

Nomor :..............................................................

Yth :...................................................................................

Di :...................................................................................

Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita :

Nama :..............................................................................................................................

Jenis Kelamin :..............................................................................................................................

Umur :..............................................................................................................................

Alamat :..............................................................................................................................

No. Hp :..............................................................................................................................

Anamnesa :

Keluhan :..............................................................................................................................

...............................................................................................................................

...............................................................................................................................

Diagnosa Sementara :.......................................................................................

Terapi / Obat yang telah diberikan :.......................................................................................

........................................................................................

........................................................................................

.........................................................................................

Demikian surat rujukan ini kami kirim. Atas perhatian dan kerjasama nya, kami ucapkan terimakasih.

Jambi,........................................

( dr. Yana Ariasti )

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