PEMERINTAHAN KABUPATEN BARITO SELATAN

UPTD PUSKESMAS PENDANG

KECAMATAN DUSUN UTARA
JL.Pembangunan No.33 RT.12 Kel.Pendang (Kode Pos 73752)
email : puskesmaspendang@gmail.com

SURAT RUJUKAN
Nomor: /Yankes-1/ -2020
Kepada Yth. Dokter IGD / Poli ................................................
DI RS .....................................................................................
Mohon pemeriksaan dan penanganan lebih lanjut :
Nama : ……………………......................................................Umur : ........
Alamat : ……………………..........................................................................
Status Pasien : Umum / BPJS / Lainnya : ................................................................
P / I/ S /A1 / A2 /...............................................................................
Nomor Peserta : ……………………..........................................................................
Anamnesa : ……………………..........................................................................
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Pemeriksaan Fisik : ……………………..........................................................................
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Diagnosa Sementara : ……………………..........................................................................
Alasan Dirujuk : ……………………..........................................................................
Terapi yang diberikan : ……………………..........................................................................
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Demikian atas bantuannyadiucapkan banyak terima kasih.
Catatan : Pendang, ...................................
1. Lembar 1 untuk RS ASLI Salam sejawat
2. Lembar 2 untuk Puskesmas
3. Surat rujukan ini berlaku hingga 30 hari
terhitung tangggal surat
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