PEMERINTAH KABUPATEN DAIRI

DINAS KESEHATAN
UPT: PUSKESMAS SIGALINGGING
Jl. Dolok Sanggul No: __ Telp: (0627)-Sigalingging Kode Pos: 22282

Nomor : / PUSK / / 2021 Kepada Yth.

Lampiran : - Dokter Jaga IGD RSUD Sidikalang
Perihal : Rujukan Pasien Kabupaten Dairi
atas nama .............................. di-
Tempat

Dengan Hormat,
Kami memohon pemeriksaan, pengobatan, dan penanganan lebih lanjut kepada pasien
dengan keterangan di bawah ini:
Nama : ...........................................................................................
Tanggal Lahir : ...........................................................................................
Jenis Kelamin : ...........................................................................................
Waktu tiba di puskesmas : ...........................................................................................
Nomor BPJS : ...........................................................................................
Kronologis puskesmas : 1. Anamnese
.......................................................................................................
.......................................................................................................
.......................................................................................................
2. Pemeriksaan fisik
.......................................................................................................
.......................................................................................................
.......................................................................................................
3. Diagnosa sementara
.......................................................................................................
4. Terapi / tindakan yang telah diberikan
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................

Sigalingging, ................................
Yang menerima rujukan Yang merujuk:
Dokter umum Puskesmas Sigalingging

.............................................. dr. Benny C. Purba, MKM

NIP. 19771128 200903 1 005
 PEMERINTAH KABUPATEN DAIRI
DINAS KESEHATAN
UPT: PUSKESMAS SIGALINGGING
Jl. Dolok Sanggul No: __ Telp: (0627)-Sigalingging Kode Pos: 22282

Nomor : / PUSK / / 2021 Kepada Yth.

Lampiran : - Dokter Jaga IGD RSUD Sidikalang
Perihal : Rujukan Pasien Kabupaten Dairi
atas nama .............................. di-
Tempat

Dengan Hormat,
Kami memohon pemeriksaan, pengobatan, dan penanganan lebih lanjut kepada pasien
dengan keterangan di bawah ini:
Nama : ...........................................................................................
Tanggal Lahir : ...........................................................................................
Jenis Kelamin : ...........................................................................................
Waktu tiba di puskesmas : ...........................................................................................
Nomor BPJS : ...........................................................................................
Kronologis puskesmas : 1. Anamnese
.......................................................................................................
.......................................................................................................
.......................................................................................................
2. Pemeriksaan fisik
.......................................................................................................
.......................................................................................................
.......................................................................................................
3. Diagnosa sementara
.......................................................................................................
4. Terapi / tindakan yang telah diberikan
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................
.......................................................................................................

Sigalingging, ................................
Yang menerima rujukan Yang merujuk:
Dokter umum Puskesmas Sigalingging

.............................................. dr. Megawati Gultom

NIP. 19930905 201903 2 018