RUJUKAN RADIOLOGI
NO : / RSU-A / / 2O
NO : / RSU-A / / 2O
POLI : ANAK/BEDAH/GIGI/INTERNA/OBGYN/UMUM
POLI : ANAK/BEDAH/GIGI/INTERNA/OBGYN/UMUM
RUANG : UGD/PERAWATAN
RUANG : UGD/PERAWATAN
NAMA : ____________________________________________________
NAMA : ____________________________________________________
UMUR/ALAMAT : ____________________________________________________
UMUR/ALAMAT : ____________________________________________________
KLINIS/DIAGNOSIS : ____________________________________________________
KLINIS/DIAGNOSIS : ____________________________________________________
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PERMINTAAN RO : ____________________________________________________
PERMINTAAN RO : ____________________________________________________
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Kendari, _____________ 20
Kendari, _____________ 20
Dokter Pengirim
Dokter Pengirim
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(__________________________)