SURAT PENGANTAR UGD

UPT PUSKESMAS TALUN Kode PPK : 13141801

KAB. BLITAR

Kepada Yth. TS di UGD

RS .....................................
Mohon Pemeriksaan dan Penanganan lebih lanjut penderita :
Nama : .......................................................................................... Umur : ........th
L/P
No. Kartu BPJS : ..........................................................................................
Diagnosa : ..........................................................................................
Telah diberikan : ..........................................................................................
Dikarenakan kondisi
penderita ................................................................................................................
...........................................................................................................................................................
......
maka penderita diarahkan ke UGD bukan melalui poli spesialis.

Atas bantuannya, banyak terimakasih

Salam Sejawat, ..........................

Dr. Desy Triyanawati

NIP. 198712172019032003