KLINIK UTAMA RAWAT INAP ARSY MEDICA KLINIK UTAMA RAWAT INAP ARSY MEDICA

JL. Raya Komplek Inkopad Blok F No. 3 RT 003/006 Kp. Bulak JL. Raya Komplek Inkopad Blok F No. 3 RT 003/006 Kp. Bulak
Desa Kalisuren, Kec. Tajurhalang, Kab.Bogor (16320) Desa Kalisuren, Kec. Tajurhalang, Kab.Bogor (16320)
Email: klinikutamaarsymedica@gmail.com Email: klinikutamaarsymedica@gmail.com
Phone. 089636069003 Phone. 089636069003

LEMBAR RUJUKAN LEMBAR RUJUKAN

No. : ............................ No. : ............................
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Kepada Yth. Kepada Yth.
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Di ................................................... Di.....................................................
Dengan hormat, Dengan hormat,
Bersama ini kami mengirim penderita Bersama ini kami mengirim penderita
Nama : Ny........................................................ Umur .........................th Nama : Ny........................................................ Umur .........................th
Pendidikan : .................................................................................................... Pendidikan : ....................................................................................................
Alamat : .................................................................................................... Alamat : ....................................................................................................
Keterangan : G............................P........................BB.................................Kg Keterangan : G............................P........................BB.................................Kg
TB...................cm Tensi...................HB..................................... TB...................cm Tensi...................HB.....................................
Pada pemeriksaan kami : Pada pemeriksaan kami :
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Telah kami berikan : ............................................................................................ Telah kami berikan : ............................................................................................
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Mohon pemeriksaan/pertolongan/perawatan selanjutnya Mohon pemeriksaan/pertolongan/perawatan selanjutnya
Sekian terima kasih Hormat kami, Sekian terima kasih Hormat kami,
Bidan Bidan

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