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.
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