PEMERINTAH KABUPATEN DHARMASRAYA

DINAS KESEHATAN
UPT RSUD SUNGAI RUMBAI
JL. Lintas Sumatera Km.42 Sungai Rumbai Provinsi Sumatera Barat (27684)
Telp. 0754 – 2371985, Fax. 0754 – 2371985
email : rsudsungairumbai@gmail.com

FOMULIR PENGADUAN RUJUKAN

Jika anda ingin menyampaikan kritik dan saran terkait pelayanan rujukan
pasien mohon ditulis pada formulir dibawah ini beserta data lengkap:
Nama :
Alamat :
No. Telephone :
Hari, Tanggal :
Kritik :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
Saran :
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................
........................................................................................................................................