PEMERINTAH KABUPATEN SANGGAU

DINAS KESEHATAN
PUSAT KESEHATAN MASYARAKAT TAYAN
Jalan Dwikora Nomor 1 Tayan Hilir (78564) Telepon (0563) 2023154
Email : puskesmas.tayan2016@gmail.com

Tayan, ……………………….
Kepada

Yth .………………………….
..............................
…………………….
No : 843.2 / / RJK / TYN / 2020 di –
Lampiran : 1 (satu) Lembar
Perihal : Rujukan Pasien ……………..

Mohon pemeriksaan dan tindakan selanjutnya kepada :

Nama : .........................................................................................................
Tanggal Lahir/ Umur : ................……………………………....................……….……………
Jenis Kelamin : ................………………………………...................………………….
Alamat : .........................................................................................................
Anamnesis : .................……………………………...................……….……………
.........................................................................................................
Pemeriksaan Fisik : .........................................................................................................
..........................................................................................................
..........................................................................................................
..........................................................................................................
Diagnosa sementara : ....................................…………………………………….……………
Terapi sementara : ....................................…………………………………….……………
..........................................................................................................

Demikian atas bantuannya diucapkan terima kasih.

Tayan, ……………………………..

Perujuk,

dr. Magdelana Corry M.C

SIP. 503/005/IPDU/DPMPTSP/2020