SURAT RUJUKAN

Kepada

Yth : ......................................................

Di : ......................................................

Mohon consult untuk pemeriksaan/tindakan/pengobatan lebih lanjut :

Nama : ........................................................................................

Umur : ........................................................................................

Pekerjaan : ........................................................................................

Alamat : ........................................................................................

Pemeriksaan fisik yang ditemukan : ........................................................................................

Tindakan operasi/therapy yang pernah/sudah dilakukan :

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

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

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

Atas kerjasamanya kami ucapkan terimakasih.

....................... , ..........................................

( )