DINAS KESEHATAN
UPT RSUD YOWARI SEN TANI
Jln. Raya Sentani - Depapre No.Telp./Fax (0967- 5195084) Doyo Baru 99352
SURAT KONSUL
Keluhan : ..................................................................................................................................................
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Pemeriksaan Fisik : KU : .......................................................... Kesadaran : ........................................................
Tanda Vital : TD : ............................. N: .......................... RR: ............................. Sb : ...............................
Kepala : ..................................................................................................................................................
Thoraks : ..................................................................................................................................................
Abdomen : ..................................................................................................................................................
Ekstremitas : ..................................................................................................................................................
Lain-lain : ..................................................................................................................................................
Laboratorium : ..................................................................................................................................................
Radiologi : ..................................................................................................................................................
Diagnosis : ..................................................................................................................................................
Terapi : ..................................................................................................................................................
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Tanggal/Jam ............................./.............
Hormat Kami,
Dr..........................................................