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PT.

AVISENA MANDIRI SEJAHTERA

RUMAH SAKIT UMUM AVISENA


Jl.Melong No. 170 Cimahi
Telp. 022 6000830

SURAT RUJUKAN KOMUNITAS


Kepada Yth,

Perkumpulan/Komunitas

Di

Tempat

Dengan hormat,

Bersama ini kami kirimkan pasien untuk perawatan lanjutan :

Nama : ......................................................................................................................................
Umur : ......................................................................................................................................
Jenis Kelamin : ......................................................................................................................................
Diagnosa : ......................................................................................................................................
Telah kami lakukan perawatan selama : ..... Hari, dengan
terapi : .............................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
.........................................................................................................................................................................
...........................................................................................................................................

Alasan rujukan : .......................................................................................................................................

Atas bantuan dan kerjasamanya kami ucapkan terima kasih

Kelompok/komunitas yang dituju Cimahi,..................................

_________________________ ____________________________

Tanda tangan dan nama jelas Tanda tangan dan nama jelas

1. Lembar 1 untuk komunitas yang dituju


2. Arsip

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