PUSKESMAS WONOTIRTO

BUKTI PELAYANAN AMBULANCE

NAMA PASIEN :..........................................................................................................

NO.KARTU :..........................................................................................................
UMUR :.................................................................Tahun, Laki / Perempuan
NO.HP :..........................................................................................................
DIAGNOSA :..........................................................................................................
ALASAN DIRUJUK :..........................................................................................................
TANGGAL DIRUJUK :..........................................................................................................
FASKES TUJUAN :..........................................................................................................
JARAK : 21 Km / 20 Km / 38 Km
NO.POL AMBULANCE : AG 866 KP
DRIVE :..........................................................................................................

Wonotirto, 2022

Faskes tujuan rujukan Dokter Perujuk

(...................................) (...................................)

Peserta / Keluarga

(...................................)