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PEMERINTAH KABUPATEN TIMOR TENGAH SELATAN

RAWAT INAP PUSKESMAS KUANFATU


KECAMATAN KUANFATU
Jalan Tsu Babys RT 07 RW 02, Desa Kuanfatu, email: pkmkuanfatu@gmail.com

SURAT PENGANTAR RAWAT INAP


No : / RI / / 2019

Mohon perawatan untuk pasien berikut :


Nama : ......................................................................................
Umur : .................. tahun / bulan / hari
Jenis Kelamin : Laki-laki / Perempuan
No. Rekam Medis : ......................................................................................
No. JKN : ......................................................................................
Alamat : ......................................................................................
Diagnosa : ......................................................................................
Instruksi Dokter : 1. .................................................................................
2. .................................................................................
3. .................................................................................
4. .................................................................................
5. .................................................................................

Pelayanan tersebut Telah diterima Kuanfatu, ................................. 2019


Penderita / Keluarga Dokter yang merawat

(.............................................) (...............................................)

--------------------------------------------------------------------------------------------------------------------------------
SURAT PENGANTAR RAWAT INAP
No : / RI / / 2019

Mohon perawatan untuk pasien berikut :


Nama : ......................................................................................
Umur : .................. tahun / bulan / hari
Jenis Kelamin : Laki-laki / Perempuan
No. Rekam Medis : ......................................................................................
No. JKN : ......................................................................................
Alamat : ......................................................................................
Diagnosa : ......................................................................................
Instruksi Dokter : 1. .................................................................................
2. .................................................................................
3. .................................................................................
4. .................................................................................
5. .................................................................................

Pelayanan tersebut Telah diterima Kuanfatu, ................................. 2019


Penderita / Keluarga Dokter yang merawat

(.................................................) (.............................................)

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