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KLINIK UMMU KULTSUM

KLINIK PRATAMA RAWAT JALAN UMUM DAN PERRSALINAN


JL. Bppn-handil II RT :04 Kelurahan Senipah Kecamatan Samboja Kab. Kutai Kartanegara
No HP : 08125890978 Email: klinikummukultsum@gmail.com

SURAT RUJUKAN
Nomor : / PMB-SR/ / 20

Dikirim Tanggal : ................................................................


Alamat rujukan : ................................................................
Petugas yang dihubungi : ................................................................
Tanggal & jam dihubungi : ................................................................
Nama pasien : ................................................................
Umur : ................................................................
Pekerjaan : ................................................................
Alamat : ................................................................
Hasil Pemeriksaan : ................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
Diagnosa : ................................................................................................................
Perawatan & terapi : ................................................................................................................
Yang dilakukan ................................................................................................................
Rencana tindak lanjut : ................................................................................................................
.................................................................................................................

Alasan Pengiriman : ................................................................................................................

Tenggarong, .................................20

BIDAN

(Nur Jannah H, AM.d. Keb )

KLINIK UMMU KULTSUM


KLINIK PRATAMA RAWAT JALAN UMUM DAN PERRSALINAN
JL. Bppn-handil II RT :04 Kelurahan Senipah Kecamatan Samboja Kab. Kutai Kartanegara
No HP : 08125890978 Email: klinikummukultsum@gmail.com

SURAT RUJUKAN
Nomor : / PMB-SR/ / 20

Dikirim Tanggal : ................................................................


Alamat rujukan : ................................................................
Petugas yang dihubungi : ................................................................
Tanggal & jam dihubungi : ................................................................
Nama pasien : ................................................................
Umur : ................................................................
Pekerjaan : ................................................................
Alamat : ................................................................
Hasil Pemeriksaan : ................................................................................................................
.................................................................................................................
.................................................................................................................
.................................................................................................................
Diagnosa : ................................................................................................................
Perawatan & terapi : ................................................................................................................
Yang dilakukan ................................................................................................................
Rencana tindak lanjut : ................................................................................................................
.................................................................................................................

Alasan Pengiriman : ................................................................................................................

....................., tgl ....................20


Bidan
(Nur Jannah H, AM.d. Keb)

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