SURAT RUJUKAN PEMERIKSAAN KESEHATAN

Nomor : ............................................

Kepada Yth.
Sejawat Dokter Pemeriksa Kesehatan Haji Lanjutan
RSU Daerah Ciamis

Dengan ini kami kirimkan Jemaah Haji

Nama : ........................................................................................................................................
Umur : ..................................... Tahun
Jenis Kelamin : ........................................................................................................................................
Alamat tinggal : ........................................................................................................................................
........................................................................................................................................
Diagnosis : ........................................................................................................................................

Untuk dilakukan Pemeriksaan dan Penatalaksanaan lebih lanjut.

Terapi yang sudah diberikan ..................................................................................................................................

.....,...................................,20...
Pemeriksa Kesehatan Haji
Puskesmas..................................

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

SURAT RUJUKAN BALIK RUJUKAN KESEHATAN

Nomor : ............................................

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

Dengan ini kami kirimkan Jemaah Haji

Nama : ........................................................................................................................................
Umur : ..................................... Tahun
Jenis Kelamin : ........................................................................................................................................
Alamat tinggal : ........................................................................................................................................
........................................................................................................................................
Diagnosis : ........................................................................................................................................

Untuk dilakukan Pemeliharaan dan penatalaksanaan lebih lanjut.

Terapi yang sudah diberikan ..................................................................................................................................

................................................................................................................................................................................

Saran Terapi Selanjutnya .......................................................................................................................................

................................................................................................................................................................................
................................................................................................................................................................................

.....,...................................,20...
Pemeriksa Kesehatan Haji
RSUD Ciamis

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