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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

SURAT RUJUKAN RM C.32


Nomor :
No. Reg :

Kepada Yth :
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Dengan Hormat,
Kami rujuk pasien atas nama :

Nama penderita : ...............................................................................


Ttl / Umur : ..............................................................................
Alamat : ...............................................................................
Diagnosa Sementara : ...............................................................................
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Hasil Pemeriksaan Fisik : .....................................................................................
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Hasil Pemeriksaan Laboratorium : .........................................................................
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Keterangan : .....................................................................................
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Pengobatan Sementara : .....................................................................................


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Palangka Raya, ………........................ 20


Dokter / Paramedis yang merujuk,

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