RM C.5
Kepada Yth.
Kepala Ruangan .................................................
RSUD Kota Palangka Raya
Dengan hormat,
Alamat :.................................................................................................................
Keluhan :.................................................................................................................
Diagnosis :................................................................................................................
Terapi :................................................................................................................
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....................................................................................................................................................
....................................................................................................................................................:
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Mohon pengobatan dan perawatan selanjutnya.
Palangkaraya, ..........................................
(...............................................................)
Mengetahui
Petugas Yang Menyerahkan Petugas Yang menerima
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