PIMPINAN DAERAH MUHAMMADIYAH KOTA METRO

SMK MUHAMMADIYAH 3 METRO

LAMPUNG
STATUS TERAKREDITASI
NSS : 402120903009 Email : smkmuhtigamet@yahoo.co.idNDS L.4212030047 FAX (0725) 47733
Jalan Soekarno-Hatta Mulyojati 16B Kec.Metro Barat Metro Provinsi Lampung Telp. (0725 ) 47733

SURAT RUJUKAN

Yth. Dokter Jaga

Di Klinik / RS .......................

Mohon pemeriksaan dan penanganan lebih lanjut terhadap pasien :

Nama :..................................................................................................
Umur :..................Tahun (L/P)
Kelas/Jurusan :..................
Alamat :..................................................................................................
Keluhan Utama :..................................................................................................
Tindakan yang sudah dilakukan :
.......................................................................................................................................
.......................................................................................................................................
Terapi/Obat yang sudah diberikan :
.......................................................................................................................................
.......................................................................................................................................
.......................................................................................................................................
Demikian suruat rujukan ini kami buat, Atas perhatian Bapak/ibu kami ucapkan
terimakasih.

Metro, ...............................
Petugas UKS

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