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RUJUKAN RADIOLOGI

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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