PEMERINTAH KABUPATEN SABU RAIJUA

DINAS KESEHATAN PENGENDALIAN PENDUDUK DAN KELUARGA BERENCANA

UPTD PUSKESMAS LEDEUNU
KECAMATAN RAIJUA
Nomor : 440/ / UPTD-PL / /2023
Lampiran :
Perihal : Rujukan
Kepada
Yth. T.S Dokter .............................................
Rumah Sakit Umum Daerah Sabu Raijua
Di-
Menia
Dengan hormat,
Bersama ini Kami rujuk seorang penderita dengan identitas sebagai berikut :
Identitas Pasien
Nama : .................................................................................................
Umur : .................................................................................................
JK : .................................................................................................
Alamat : .................................................................................................
No Kartu BPJS/Asuransi : .................................................................................................
Keluhan Utama Pasien : ..............................................................................................................................................
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Keadaan Umum :
1) Kesadaran :
2) TTV : TD :.....................mmHG Nadi : .........................x/Menit
BB :......................Kg Suhu : .........................c
Pemeriksaan Fisik : .............................................................................................................................................................
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Diagnosa sementara : ............................................................................................................................................................
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Pengobatan dan tindakan yang sudah diberikan :
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Mohon pemeriksaan dan perawatan selanjutnya kepada penderita tersebut. Atas bantuan dan kerja sama yang
baik kami ucapkan terima kasih.
Ledeunu, ………………………………2023
Yang Merujuk
PEMERINTAH KABUPATEN SABU RAIJUA
DINAS KESEHATAN PENGENDALIAN PENDUDUK
DAN KELUARGA BERENCANA
KECAMATAN RAIJUA
PUSKESMAS LEDEUNU

Nomor : 440/271/ PL /VIII /2019

Lampiran :-
Perihal : Rujukan BPJS (ASKES/JAMKESMAS/JAMKESDA/KIS)

Kepada
Yth. Direktur RS TC Hiler
Di_
Maumere

Dengan hormat
Kami rujuk seorang penderita dengan identitas sebagai berikut:
Nama : Tn Ie Rede
Umur : 77 tahun
JK : Laki-laki
Alamat : RT 16/RW 08 Kelurahan Ledeunu
No Kartu Asuransi Kes : 0001580141305
Gejala :

Diagnose sementara :

Pengobatan dan tindakan yang sudah diberikan :

Mohon pemeriksaan dan perawatan selanjutnya kepada penderita tersebut. Atas bantuan dan kerja sama yang
baik kami ucapkan terima kasih.
Ledeunu, 2019
Yang merujuk
dr. Andrew H D Simatupang