Anda di halaman 1dari 1

PEMERINTAH KOTA PALANGKA RAYA

RUMAH SAKIT UMUM KELAS D


KOTA PALANGKA RAYA
Jl. MahirMahar Km. 18,5Telp. (0536) 3246101 Kalampangan 73114
Email.rsupalangkaraya@gmail.com

RM C.5
Kepada Yth.
Kepala Ruangan .................................................
RSUD Kota Palangka Raya

Dengan hormat,

Dengan ini kami kirimkan pasien :

Nama :............................................................... Umur ......................................

Jenis Kelamin : Laki-laki / Perempuan

Alamat :.................................................................................................................

Keluhan :.................................................................................................................

Diagnosis :................................................................................................................

Terapi :................................................................................................................

....................................................................................................................................................
....................................................................................................................................................
....................................................................................................................................................:
....................................................................................................................................................
Mohon pengobatan dan perawatan selanjutnya.

Palangkaraya, ..........................................

(...............................................................)

Mengetahui
Petugas Yang Menyerahkan Petugas Yang menerima

(.............................................) (...................................................)

Anda mungkin juga menyukai