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PEMERINTAH KABUPATEN TEGAL

DINAS KESEHATAN
PUSKESMAS TALANG
Jl. Projosumarto II Kec. Talang Kab. Tegal Telp. (0283) 3447545

SURAT PERINTAH RAWAT INAP / PONED


Mohon rawat,
No. RM : ....................................................................................................................
Nama : ........................................................................................................ L / P
Tgl lahir : ........................................................................................................( th)
Alamat : ....................................................................................................................
Diagnosa : ....................................................................................................................
Intruksi therapi : ....................................................................................................................
Talang, ...............................20
Dokter yang memeriksa

(.........................................)
Nama dan tanda tangan

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

PEMERINTAH KABUPATEN TEGAL


DINAS KESEHATAN
PUSKESMAS TALANG
Jl. Projosumarto II Kec. Talang Kab. Tegal Telp. (0283) 3447545

SURAT PERINTAH RAWAT INAP / PONED


Mohon rawat,
No. RM : ....................................................................................................................
Nama : ........................................................................................................ L / P
Tgl lahir : ........................................................................................................( th)
Alamat : ....................................................................................................................
Diagnosa : ....................................................................................................................
Intruksi therapi : ....................................................................................................................
Talang, ...............................20
Dokter yang memeriksa

(.........................................)
Nama dan tanda tangan

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