SURAT RUJUKAN PEMERIKSAAN KESEHATAN

Nomor

Kepada Yth.
Sejawat dokter pemeriksaan Kesehatan Lanjutan
RS.............................................................

Dengan ini kami kirimkan jamaah haji:

Nama : ...................................................................................................
Bin/binti .....................................................................................
Umur : ..............Tahun
Jenis Kelamin : ..................................................................................................
Alamat tinggal : .................................................................................................
..................................................................................................
Kab/kota...................................................................................
Diagnosis : .................................................................................................
................................................................................................
.................................................................................................
Untuk dilakukan pemeriksaan dan penatalaksanaan lebih lanjut.
Tetapi yang sudah di berikan .............................................................................
............................................................................................................................
...........................................................................................................................
...........................................................................................................................
..................20........
Puskesmas Kesehatan Dasar
Puskesmas ..........................

dr.......................................
NIP/SIP

Keterangan
 Kode diagnosis ditulis menurut kode ICD-X
 Dibuat rangkap 3 untuk keperlian
1.Puskesmas
2. Dinas Kesehatan kabupaten/kota
3. Arsip
 SURAT RUJUKAN BALIK
PEMERISAAN KESEHATAN
Nomor

Kepada Yth.
Sejawat Dokter Pemeriksa Kesehatan Dokter
Puskesmas......................................................

Dengan ini kami kirimkan jamaah haji.

Nama : ..................................................................................................
Bin/binti ...................................................................................
Umur : ..............tahun
Jenis Kelamin : ..................................................................................................
Alamat tinggal : ..................................................................................................
Kab/kota....................................................................................
Diagnosis : ..................................................................................................
...................................................................................................
....................................................................................................
Untuk di lakukan pemeriksaan kesehatan lebih lanjut.
Terapi yang sudah di berikan ............................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................
Saran Terapi selanjutnya....................................................................................
...........................................................................................................................
...........................................................................................................................
...........................................................................................................................

.......................20......
Pemeriksa Kesehatan Lanjutan
Rs.............................................

dr..............................................
NIP/SIP

Keterangan
 Kode diagnosis ditulis menurut kode ICD-X
 Dibuat rangkap 3 untuk keperlian
1.Puskesmas
2. Dinas Kesehatan kabupaten/kota
3. Arsip