PEMERINTAH KABUPATEN MESUJI

DINAS KESEHATAN
BLUD UPT PUSKESMAS RAWAT INAP BUKOPOSO
Jln. Kesehatan No 1 Desa Bukoposo Kec. Way Serdang Kab. Mesuji Kode Pos 34684

SURAT PENGANTAR RUJUKAN

Nomor : 800/................/ SPR/BLUD-UPT/PKM–BP/........./20.......

Yth dokter .................................................

Di RS........................................................

Mohon pemeriksaan dan penatalaksanaan lebih lanjut pada pasien :

Nama : .......................................................
No. RM :........................................................
Jenis kelamin : Laki-laki / Perempuan*
Tanggal lahir / Umur :............ Tahun/ Bulan/ Hari*
Alamat : .......................................................

ANAMNESA :
............................................................................................................................................................
..........................................................................................................................................................

PEMERIKSAAN FISIK :
............................................................................................................................................................
..........................................................................................................................................................

DIAGNOSA :
...........................................................................................................................................................
...........................................................................................................................................................

TERAPI :
............................................................................................................................................................
............................................................................................................................................................
.........................................................................................................................................................

RESUME :
............................................................................................................................................................
..........................................................................................................................................................

Demikian surat rujukan ini kami kirim, kami mohon balasan atas suratrujukan ini. Atas bantuan
dan kerjasamanya kami ucapkan terimakasih.

Bukoposo, ........................... 20...

Hormat kami,

dr. .......................................
NIP..............................................

Keterangan :* Coret yang tidakperlu

PEMERINTAH KABUPATEN MESUJI
 DINAS KESEHATAN
PUSKESMAS RAWAT INAP BUKOPOSO
Jln. Kesehatan No 1 Desa Bukoposo Kec. Way Serdang Kab. Mesuji Kode Pos 34684

SURAT PENGANTAR RUJUKAN

Nomor : 800/................/ SPR/PKM–BP/........./20.......

Yth dokter .................................................

Di RS........................................................

Mohon pemeriksaan dan penatalaksanaan lebih lanjut pada pasien :

Nama : .......................................................
No. RM :........................................................
Jenis kelamin : Laki-laki / Perempuan*
Tanggal lahir / Umur :............ Tahun/ Bulan/ Hari*
Alamat : .......................................................

ANAMNESA :
............................................................................................................................................................
..........................................................................................................................................................

PEMERIKSAAN FISIK :
............................................................................................................................................................
..........................................................................................................................................................

DIAGNOSA :
...........................................................................................................................................................
...........................................................................................................................................................

TERAPI :
............................................................................................................................................................
............................................................................................................................................................
.........................................................................................................................................................

RESUME :
............................................................................................................................................................
..........................................................................................................................................................

Demikian surat rujukan ini kami kirim, kami mohon balasan atas suratrujukan ini. Atas bantuan
dan kerjasamanya kami ucapkan terimakasih.

Bukoposo, ........................... 20...

Hormat kami,

dr. .......................................
NIP..............................................

Keterangan :* Coret yang tidakperlu

PEMERINTAH KABUPATEN MESUJI
DINAS KESEHATAN
 BLUD UPT PUSKESMAS RAWAT INAP BUKOPOSO
Jln. Kesehatan No 1 Desa Bukoposo Kec. Way Serdang Kab. Mesuji Kode Pos 34684

SURAT PENGANTAR RUJUKAN

Nomor : 800/................/ SPR/PKM–BP/........./20.......

Ythdokter .................................................
Di RS........................................................

Mohonpemeriksaandanpenatalaksanaanlebihlanjutpadapasien :
Nama : .......................................................
Jeniskelamin : Laki-laki / Perempuan*
Tanggallahir / Umur :............ Tahun/ Bulan/ Hari*
Alamat : .......................................................

ANAMNESA :
............................................................................................................................................................
..........................................................................................................................................................

PEMERIKSAAN FISIK :
............................................................................................................................................................
..........................................................................................................................................................

DIAGNOSA :
...........................................................................................................................................................
...........................................................................................................................................................

TERAPI :
............................................................................................................................................................
............................................................................................................................................................
.........................................................................................................................................................

RESUME :
............................................................................................................................................................
..........................................................................................................................................................

Demikian surat rujukan ini kami kirim, kami mohon balasan atas suratrujukan ini. Atas bantuan
dan kerjasamanya kami ucapkan terimakasih.

Bukoposo, ........................... 20...

Hormat kami,

dr. Khusnul Marsrilia

NIP. 19900305 201503 2 006

Keterangan :* Coret yang tidakperlu

PEMERINTAH KABUPATEN MESUJI

DINAS KESEHATAN
BLUD UPT PUSKESMAS RAWAT INAP BUKOPOSO
 Jln. Kesehatan No 1 Kp. Bukoposo Kec. Way Serdang Kab. Mesuji Kode Pos 34684

SURAT PENGANTAR RUJUKAN

Nomor : 800/................/ SPR/PKM–BP/........./20.......

Ythdokter .................................................
Di RS........................................................

Mohonpemeriksaandanpenatalaksanaanlebihlanjutpadapasien :
Nama : .......................................................
Jeniskelamin : Laki-laki / Perempuan*
Tanggallahir / Umur :............ Tahun/ Bulan/ Hari*
Alamat : .......................................................

ANAMNESA :
............................................................................................................................................................
......................................................................................................................

PEMERIKSAAN FISIK :
............................................................................................................................................................
............................................................................................................................................................
...................................................................................................

DIAGNOSA :
.........................................................................................................................................
.........................................................................................................................................

TERAPI :
............................................................................................................................................................
............................................................................................................................................................
............................................................................................................................................................
................................................................................

RESUME :
............................................................................................................................................................
............................................................................................................................................................
...................................................................................................

Demikiansuratrujukanini kami kirim, kami mohonbalasanatassuratrujukanini.

Atasbantuandankerjasamanya kami ucapkanterimakasih.

Bukoposo, ........................... 20...

Hormat kami,

dr. Zuli Eko Wahyudi

NIP.19880727 201403 1 003
Keterangan :* Coret yang tidakperlu