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PEMERINTAH KABUPATEN KUTAI TIMUR

DINAS KESEHATAN
BLUD PUSKESMAS MUARA WAHAU I
Jln. PNPM No. 002, RT 005 Desa Muara Wahau, Kode Pos 75655
Email: pusk.muarawahau@gmail.com

Muara Wahau,........................................

SURAT RUJUKAN INTERNAL

Unit Yang Mengirim : ...........................................................................................


Unit Yang dituju : ...........................................................................................
Nama Pelanggan : ...........................................................................................
Umur : ...........................................................................................
Alamat : ...........................................................................................
Diagnosa : ...........................................................................................
Rujukan : ...........................................................................................
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Demikian atas bantuannya diucapkan terima kasih.

PENGIRIM RUJUKAN INTERNAL

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SURAT RUJUKAN BALIK

Unit yang Menerima :..........................................................................................


Unit yang Mengirim :...........................................................................................
Jawaban Rujukan :...........................................................................................
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Penerima Rujukan Internal

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