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Kepada Yth,

Admisi Rawat Inap


Rumah Sakit Primaya PGI Cikini

SURAT PENGANTAR RAWAT


Mohon diberikan perawatan bagi pasien:

Nama : .............................................................................................................L/P

Tanggal Lahir : ....................................................................................................................

No. Med. Rec : ....................................................................................................................

Diagnosis : ....................................................................................................................

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

Dokter yang merawat : ....................................................................................................................

Tindakan/Pengobatan : ....................................................................................................................

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

Kebutuhan Ruangan : Rawat Inap Biasa HCU ICU

Perina NICU PICU

Isolasi Covid Isolasi TB

Bagian Pengirim : Instalasi Gawat Darurat Instalasi Rawat Jalan

Jakarta, ............................. 20........

Dokter yang memeriksa / mengirim

dr. .................................................

Form/PHG-PHPC/MED-001//Rev.00

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