SURAT RUJUKAN PASIEN

Referral Letter
Nomor : 03 /Ref / XII / 2023

Lumut Balai, 02 Desember 2023

Kepada Yth./ To

dr. Internist
- Di / at
Tempat,

Bersama ini saya rujuk pasien :

Nama : Ramli
Name

Umur : 53
Age

Status : Karyawan
Status

Perusahaan : PT. CPM

Company

Departemen : Surveyor
Deptartement

Supervisor :
Supervisor

Diagnosis : Diabetes Type II

Diagnose

Pengobatan Sementara : -
Therapy

Mohon pengobatan selanjutnya di bidang sejawat. Jawaban dan saran dari sejawat sangat
saya harapkan.
I would be grateful for your further examination. Your prompt reply would be highly appreciated.

Salam sejawat,
Yours sincerely,

__________________________
Consortium Doctor

Medical Referral Letter Form @August 2023

 SURAT JAWABAN KONSULTASI
Consulting Discharge Letter

Kepada Yth./ To :
dr. .................................................
- Di/ at
.............................................

Yth. Petugas Medis/ Dear Medic,

Menjawab konsul saudara mengenai orang sakit/ Concerning the following patient :

N a m a/ Name
U m u r/ Age
Perusahaan/ Company
dengan diagnosa/ masalah
with diagnose/ problem
: ……………..........................................………
: …………….....................................................
: …………………………………….…………..…
: ........................................................................
........................................................................

Adapun hasil - hasil pemeriksaan yang didapatkan :

Please find the following examination / treatment carried out during the care :

Pemeriksaan fisik :
Physical Assessment

Diagnosa :
Diagnose

Pengobatan :
Therapy

Perencanaan :
Planning

Atas konsul Ts. kami ucapkan terima kasih/ Thank you for referring this patient to me.

……………, ……………………
Salam Sejawat,
Yours sincerely,

dr._________ _______
Medical Referral Letter Form @August 2023