PEMERINTAH KABUPATEN PASER

DINAS KESEHATAN
UPTD PUSKESMAS PASIR BELENGKONG
Alamat : Jl. Sultan Adam No. 13 Rt. 007 Kec. Pasir Belengkong Kode Pos: 76271

SURAT PENGANTAR RUJUKAN

PASIEN PUSKESMAS PASIR BELENGKONG
Nomor : / Ru/UPTD-PKM.PB/ /20

Kepada Yth
TS :
di Poliklinik / UGD

Mohon pemeriksaan dan tindakan lebih lanjut terhadap pasien / penderita :

Nama :..........................................................................................................
Umur :..........................................................................................................
Pekerjaan :..........................................................................................................
Alamat :..........................................................................................................

Datang Ke Puskesmas dengan :

Keluhan / Anamnesa :..............................................................................................
....................................................................................................................................
....................................................................................................................................
Pemeriksaan Fisik :...............................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Diagnosis sementara :
Tindakan/ terapi sementara yang sudah diberikan :...............................................
....................................................................................................................................
....................................................................................................................................
Atas perhatian dan kerjasama T.S , banyak terimakasih serta informasi / saran selanjutnya atas
pasien / penderita tersebut.

Pasir Belengkong, ........................20

Penanggung Jawab Medis

PKM Pasir Belengkong

dr. Corina Primanda Rahman

NIP.19950901 202203 2 014
 PEMERINTAH KABUPATEN PASER
DINAS KESEHATAN
UPTD PUSKESMAS PASIR BELENGKONG
Alamat : Jl. Sultan Adam No. 13 Rt. 007 Kec. Pasir Belengkong Kode Pos: 76271

SURAT PENGANTAR RUJUKAN

PASIEN PUSKESMAS PASIR BELENGKONG

Nomor : / Ru/UPTD-PKM.PB/ /20

Kepada Yth
TS :
di Poliklinik / UGD

Mohon pemeriksaan dan tindakan lebih lanjut terhadap pasien / penderita :

Nama :..........................................................................................................
Umur :..........................................................................................................
Pekerjaan :..........................................................................................................
Alamat :..........................................................................................................

Datang Ke Puskesmas dengan :

Keluhan / Anamnesa :............................................................................
....................................................................................................................................
....................................................................................................................................
Pemeriksaan Fisik :..............................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
....................................................................................................................................
Diagnosis sementara :
Tindakan/ terapi sementara yang sudah diberikan :...............................................
....................................................................................................................................
....................................................................................................................................
Atas perhatian dan kerjasama T.S , banyak terimakasih serta informasi / saran
selanjutnya atas pasien / penderita tersebut.

Pasir Belengkong, ........................20

Penanggung Jawab Medis

PKM Pasir Belengkong

dr. Raden Ahmad Yusuf

NIP.19781122 201412 1 001