PEMERINTAH KABUPATEN PURWOREJO

DINAS KESEHATAN
PUSKESMAS DADIREJO
Jl. Yogyakarta KM. 18 Dadirejo, Bagelen Purworejo
Kode Pos: 54174 Telp. 08112541581
Email: puskesmasdadirejo@yahoo.co.id

SURAT RUJUKAN UKM

Kepada :

Yth. .............................

Di ............................…

Mohon bantuan pemeriksaan, perawatan dan pengobatan selanjutnya pada :

Nama : ...........................................................................................

Usia : ............................................................................................

Jenis Kelamin : ............................................................................................

Alamat : ...........................................................................................

Berdasarkan hasil penjaringan/ pemeriksaan kesehatan yang telah dilaksanakan

pada:

Hari/ Tanggal : .............................................................................................

Tempat : .............................................................................................

Didapatkan hasil : .............................................................................................

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

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

....................., ...................................

Petugas

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