SURAT RUJUKAN

Yth Bapak / Ibu

Di
...............................

Mohon pemeriksaan dan pengobatan lebih lanjut terhadap penderita

Nama : ...........................................................
Jenis kelamin : ...........................................................
Umur : ...........................................................
No Telepon : ...........................................................
Alamat rumah : ...........................................................

Anamnese

Keluhan : .............................................................................................
.............................................................................................
.............................................................................................
.............................................................................................

Diagnosa sementara : .............................................................................................

.............................................................................................
.............................................................................................
.............................................................................................

Demikian surat rujukan ini kami kirim, kami mohon balasan atsa surat rujukan ini.
Atas perhatian Bapak / Ibu kami ucap kan Terima Kasih.

Hormat Kami

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