LEMBAR KONSULTASI RM.

16
NO. RM :
NAMA : UMUR :
ALAMAT : RUANG :

TGL/
PERMINTAAN KONSUL
JAM

KEPADA : Yth. dr.___________________________

Dengan hormat,

Ringkasan singkat pemeriksaan, _________________________________________

____________________________________________________________________
____________________________________________________________________
Konsultasi___________________________________________________________
____________________________________________________________________
____________________________________________________________________
Paraf Dokter

____________________

TGL /
JAWABAN KONSULTASI
JAM

KEPADA : Yth. dr.___________________________

Dengan hormat,

Pasien telah kami periksa pada tanggal, ___________________________________

___________________________________________________________________
___________________________________________________________________
Kesimpulan _________________________________________________________
___________________________________________________________________
___________________________________________________________________
Therapy ____________________________________________________________
___________________________________________________________________
Saran ______________________________________________________________
___________________________________________________________________
Paraf Dokter

__________________