Rumah Sakit Ibu dan Anak “IBUNDA”

RM :

Jl. A. Syairani RT.004 RW.002 Kelurahan Sarang Halang Kecamatan Pelaihari

Kabupaten Tanah Laut Kalimantan Selatan
Telp. 0853 49483 703

RUJUKAN BALIK

Kepada Yth Pelaihari, ............................................

Teman Sejawat
..................................................................... Jam/Time :
Di tempat

Dengan Hormat,
Kami kirimkan kembali pasien saudara,
Nama : .....................................
Tanggal Lahir : ..................................... L/P
Diagnosa : .............................................................
Pemeriksaan yang telah dilakukan:
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Pengobatan & tindakan yang telah diberikan

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Kondisi Saat pulang : Sembuh Perbaikan Meninggal Cacat Pakai alat bantu
Dan lain-lain

Kontrol lanjutan,..............................................................................................................................................................
Rencana Tindakan/ Pengobatan selanjutnya...........................................................................................................................
Keterangan lainnya/ saran,
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Demikian kami sampaikan, atas kerjasama yang baik kami mengucapkan terima kasih.
Hormat kami ,
Dokter Penanggung Jawab Pasien

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